Southville International Schoof and Colleges

COLLEGE OF N.,URl,ING

RLE DAILY LOG

NAME: _ _ _ _ _ _ _ _ · -- - - AREA: _ _ _ _ __
GROUP/SECTION: _ _ _ _ _ _ _ _ _ ·DATE: _ _
CLINICAL INSTRUCTOR:

OBJECTIVES:
1.

2.
3.

SKILLS LEARNED:
L . 4.
2. 5.
3. 6.

REFLECTIVE LEARNING EXPERIENCE:

Day 1

Day2

Day 3

Evaluated by:

Clinical Instructor
(Signat1ire over printed name)
 Southville International School and Colleges
1281 Tropical Ave . corner Lu•ernbouf9 SI., BF International, Las Pi/las City ·
S ISC iC.JSF• NS G -0(18 R ev 000 -l .' l\l/ 10 Tel. No.: 820-8702 10 03: Fax No.: 620-87·18

COLLEGE OF NURSING

Name or Sludenl:
Clinical Ro1allon a-,-
, - - - - -- - - - - - - - Level: _ _ __ _ _ Inclusive Dates: _ _ _ _ _ _ _ _ _ _ _ _ __

ON-GOING ASSESSMENT IN CLINICAL SETTING

Patient's Nome: _ _ __ _ _ _ _ _ _ _ (Initials Only)
Attending MD: _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ Allergies: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

r
Diagnosis; _ _ _ _ _ _ ____ __ _ _ _ __

:
I BR
• Dongle J Q;
1
· 1
·, Type ol Activity ;~ C~h_o~i~r _ _ _ _ __ ___ l :3 "'
::, lO
uU
~i
Amb
!-::: R-::P~ -- - - - -- - -- i
!l-::
]
r-::B-::S-::C~------- - -------- --- 1
.,..
<<
>
u
c-2-=============--- ---_-_-J-
I1-cc----- - - -- -,-==c.._--
How Accomplished I Self ---- -- --l IV 11 3

, , Turn and Position

I
I WiO, Ass t
I Sel f
,._ Bed in Lowest Position
'
W
' Coll Beil Wiihin ·Reoch

.
~2• A ssisted
' -· Seizure Precautions
'I
:. ' Range of Motion ,.~P~a~•~s'-,v~e' - - ---''---'-- -- - _ j
J Acti v e
L____ _.._'-A~s= ir'°'a'-'t'-'io"-n'-'-
P~re=-c=a""u""tl"o""
' n '--- - - -- -
: lnlllols

H
Deep Breath and J
Cough
i -=-
s '°'
eC::
d~B~o
-'-t;ch-,-;S"'h_o_w
_ e-, - - t-;S:-e-;1-:-
f - -- - -- - - - - i i
1 , {Circle One/ W i th Asst . SKIN BREAKDOW.N SCREEN/BRADEN SCALE
r·
I Com o lele I
I Oral Core Sensory Perception .I. Completely limi ted
j
I' Ability to respond lo
2. Very limited
' !!,! I Perl Care
3 . Slightly limiteo
l? I SIi z B 0 IIl
I' ,-.
::c: Cath Core (Q Shift) I
I Discomfort
4, No Impairmen t .I
I I Linen Chan c e
j PM Care
I
I Moisture - degree I , Constantly moist
2 . Very moist
i II
to which skin Is
exposed to moisture 3. Occasionally moist
4 . Rarely mois t
!' l NPO

I z
0
Meals Taken By Se ll Feed
Assl / Sue ervisian
Total Feed
I

i
l
'
Activity - degree of
physical activity
I. 8edfosl
2. Chalrfasl
3 . Walks occoslonolly
4. Walles frequently
100%
s
z
Amount of Maal(1)
Taken 50% Mobility - ability to
1, Completely
lmmot:>lle
Le<J lhan 50% I change and control 2. Very limited
Per O rder
Supplements Taken
I Re fused
Void ad lib
I body position 3. Sllghlly limited
4, No llmilolions
z I, Very POOr

I
Folev Cath I I
0
Urine I Nutrition - usual
2 . Probably I
'< Incant

'
I
z
~
Incontinent

lnconllnenl
Ii
Iifood inl oke po11ern inadequate
3 . Adequate
4 . Excellenl
I
I
i
Stools I . Problem
ff of Sl o ols
2. PQtential problem
- Chest Tube
R or L I To SLJ Ctlon
O ff suction
! :
Frlc:llon and Shetor
3 . No apparent
problem
.I
'
z Drains Type : _ _ _ ~F.!I Score
- :
1--- - -- - -- - ,--;;c...cc-':-t,,·o~
.. ,,= ~ -- - - - - - - '. ~ature
- =i
NGT m p ed _ __) NOTES :
::C: Plocemenl / Resid ucl
: er ii
,__S_u_c_ll_o_n_ (cE,-nf Tro c h
l im es/Shill) NT
j Oral
lnlllals

DAI LY GUIDE:
Doy 1 Asses sment, Gather Data - Identifying Problems
Da y 2 On•golng As s essmen t - Prioritize Problem - Set Goals ..., Interventions
Day 3 On-1olng Assessment - Interventions - Outcome/Evaluat io n
 _ DATE:
No Problem, Alert. orie nleo •3. speech c leor.
ldenlHled
I DATE:
11ren91h eciuol in OIi exlremllles,
No Problems Bowel 1ound1 normal. abdomen
-
I
punils ea uol o nd reocllve
lOC 0Alerl
ldtinlWlod sofl. non-lender ond non•
lelhorgic dis I ended
Oblunded I Abdomen
-I
<
u
Orlenlollon
Speech I
O Pe rson
o
unrestoble
ShXTl!>d 0 Aphasic I' .,,-
<
z
0 Non-tende r
d Non-dlstoncled
lender
Dlsle ncle d
'
'
Bowel Sounds 0 Hypoocllve I
,-
0 Dlulnou l4J
Hvz) erocllve '
I ,- Nau1eo O Yl! I
0 Ataxia NO ; z Vomllln"
..."':::,
:z:
Pupil R&ocllan R
l
Brisk
0 0risk 0 Slun n ish
F'utoo
D Fl.,ed
0
•... Slool i.( o Normol
0Yel
Consnpollon
:

Vl1lon 0 Clear D 81vrr ecl O Fi xed "' ' Diorrhllo Tdrry I

I Extremity StrenQlh RUE Strong Ftocckt
__
-~ lnconllnen l 0 Brie hl Red !
I
II LUE 0 Strong F1occld GI Tube Type
Rll Strong 0 FIOCCld
I

I' Neuro Comments

LLE 0 Strano o Flaccid ' OstomyType

GI Comm•nls
i
I ;
i
Na Problems D Normal he ar! sounds. re gular

. I
No Problems 0 Urine cleor/)'flffow: dl!n,es or,y
ldenlifl•d rt1ylt11"t"l. c olor pink.. ikin w orm/t11y, Identified reproduc tive problem,
noedemo
Rhr!h m
::3 1 Regutor Irreg ular i ~ Color Ye llow Amber BIOOdy
:::,
u
H"ort Sounds : Normo1 Ab no rmal l oracler Cloo r O Cloud O Clols 7
Skin Color , 0 Pillk Du sk y 0 Fluslled Voiding
""< Skin lomo•roture , o Worm Conllnge'n l rnco,vlnen1 .
> Cote! 0 Frequency O Urgen1

.
Q !
~emo None Yes. loco lion: 0 Burnh, O Anuria
c. oolllorv Rollll , Brisk Prolonoed GU Tube Type Foley Supropubic
JVD ;
< Pulses :
Externol O Uro stom
_ _ _ _ _ __
u RoCliol ond Pedol Puls~• Presen t Femola Vagina!
Al?.'2Q!!!'CI Finding :. I. Drainage
CV Comments
i
II l Mole P&nlle No D Yes _ _ _ _ _ _ __
; Discharge
No Problems a No diilress. lur.g, clear bilolerally. i
i
GU Comm,.nls
ld .. nlnled i
ii · Re1olrollon1 1
a
no coug11
No Distress o •,sor\eo
I
No Problem, D Normal olfecl. lnloct lhouglil
i R Rhonchl I ld1tntifled processes. under!londs
i
. II Alfttcl/Mood
[
, Wheezes D Crockles hos liotlzalion/lx
Brealh Sounds Diminisheo D Ablenl 1 Normal D Ang,y/Ho1lile/Agila !e<J
tl Clear Rhonchl u Flo1/Wllhdrown Unoble lo
w11ee,es O Crockle1 i3 I Assess
O O!minisned Ab1en1 0 Though! lriloc l lJnoble,_ lc-,-)s-,-
o-ss
Processes
C!:'f Produclive 0 lnslghl
Abnormol Findinc,:
Spulum D None Cleo, CJ White Greem X D Understa nds ,,aspilolizo1io,v1x

.,..
Yellov, Brown Bloody u Does not unoersh11",ct..
0 2 Device None O NC 1.-.0>k D Collar V,
1·,osplta:izc :lon/tx
,-Artlllclol Airway None lroch D Unable lo assess
i ~esplrolory
J Psych Comments
! Comments
HIGHLY PRIORITIZED

Nursing Problem: - - - - - - - - - - - - - = : - : : : :--:::-::- : - - - - - - - , - - - - - - - - - - - - - - -

CARE PLAN
I
I
Nurslne Dlacnosls Relatorl Drug
Therapeutics
Relatod lob
Diagnostics I
I
Short Torm Goal Nursing lntorv~ntlon
II Evoluotlon/Outcor,i,
I I
·-
I
i
I
!

!
'
'

i
~-~-- I
I
CRITERIA: _J
Content/ Completeness - 45% Accuracy • 40% Punctuality - 1S%
 ,~~/ Southvill<c? International School and (oiiczges
College of Nursing
Record of Case Conferences in Clinical Area
Level: Semester· Academic Year:
No. Date Patient Case/Topic/s Area/Ward Cl Signature Remarks
Community Hospital (Pass or Fail)
1.
2.
3.
4:
I!
5. l
6. i
I
- !
7. - I
8. \
I
I
9. •':c- -
10.
\
Prepared by:
Name of Student
Noted by:
Level Coordinator
 College of Nursing
Patient-Centered Care Report Grading Shee~
Name:
Exceeds Expectations
91% and above
Introduction (patient and You introduced the patient and
problem) lnciuded pertinent data In a dear .
and comprehensive.manner. You
thoroughly explained the
progression of the current problem.
Nursing Physical Assessment You obtained assessment data that
is sufficient and appropriate from at
least four sources.
Patho-physiology Showed an exhaustive concept
mapping of the disease (What are
the symptoms? What causes it?).
There were very clear connections
~tween concepts. -· · - ----- - ··connections-between .concepts:-- --
Actual Management and Outlined the current medical
Related~rreatments management and treatments.
Comparatively analyzed and fully
discussed management based on
standards of care.
Nursing Care You identify three problems that are
appropriate and supported by 100%
of the assess·ment data.
Prior itization You appropriately prioritized all
three identified problems with dear
justifications.
I
Technical Writing (APA Citations Complete/Correct
& Refe rencing)
Cl inical Instructor: _ _ _ _ _ _ _ _ _ _ __
Meets Expectations
83-90%
You introduced the patient and
included pertinent data. You
explained and covered important
details regarding the progression of
the current problem.
You obtained appropriate
assessment data from at least three
sources.
Showed a partially comprehensive
concept mapping of the disease
(What are the symptoms? What
causes It?). There were dear '
·outlined the current medical
management and treatments.
Analyzed and discussed
management based on standards of
care.
You identify three problems that are
appropriate and supported by 80%
of the assessment data . ·
You appropriately prioritized two of
the identified problems with clear
justifications.
Complete/Some minor errors
Over-all Mark:
Needs Improvement
75-82%
You introduced the patient and but
failed to include all pertinent data.
You attempted to explain the
progression of the current problem.
You obtained some appropriate but
lacking assessment data from two
sources.
Showed a limited / simplistic .
concept mapping of the disease
(What are the symptoms? What
cau~.:Ehere were some
connections between concepts.
Partially outlined the current
medical management and
treatments. Attempted to analyze
and discuss management based on
standards of care.
.You identify three problems that are
minimally appropriate and
supported by 60% the assessment
data.
You appropriately prioritized only
one of the three identified problems•
with the correct justification.
Incomplete /incorrect
Date: _ _ _ _ _ _ _ _ __
Unacceptable
0-74%
You introduced the patie°M and but
failed to include pertinent data. You
failed to explain the progression of
the current P!"Oblem.
You obtained minimal and
inappropriate assessment data from
two or fewer sources.
a
Showed vague/inaccurate a,ncept
mapping of the disease (What are
the symptoms? What causes it?).
There were little or no connections
between concepts;
Partially outlined the airrent
medical management and
treatments. Failed to analyze and
discuss management based on
standards of-care.
You Identify three problems that are
Inappropriate and supported by less
than 50¾ of the assessment data.
You did not appropriately prioritize
any of the identified problems.
Lacking/None
 SISC College of Nursing
BSN RELATED LEARNING EXPERIENCE PERFORMANCE ASSESSMENT

Student: Year Level: Semester:

Inclusive Dates of Rotation: Instructor: Cllnlcal Rotation Area:

Part I. CLINICAL EVALUATION TOOL

Introduction: This clinical evaluation tool consists of nine essential competencies with specific performance
criteria. The nine competencies were drawn from: SISC BSN Graduate / Program outcome and competencies
aligned with 5Cs institutional core values, CHED Memorandum Order No.15 series of 2017 and Philippine
Professional Nursing Practice Standards (PPNPS Resolution No.22 Series 2017). The competencies are
benchmarked with AACN's Essentials of Baccalaureate Education for Professional Nursing Practice (2008),
Quality and Safety Education in Nursing (2007) and NMC Standards for Pre-Registration Nursing Education
(2010) .

The performance criteria for each competency include cognitive, affective, and psychomotor domains of learning
and provide an evaluation of an individual student's performance during his/her clinical rotation in the varied
areas throughout the BSN program . This clinical evaluation report will be kept in the student's file to provide
evidence of student's performance and progress through the nursing curriculum. It also provides standard
measures for student, course, and program evaluation.

This clinical evaluation tool is to be used after every clinical rotation together with the self-evaluation Lasater
Performance Toof (Part 2). This structured evaluation is completed and shared with the student at the
conclusion of the rotation. The tool can also be used at other times during the rotation and can serve as the
basis for a learning contract.

Instructions: Faculty will rate students on each of nine competencies using the designated rating scale,
considering the quality of the performance (Almost Never Exhibits to Almost Always Exhibits). To determine
the rating for each competency, faculty will consider student performance on the specific performance criteria
and will arrive at a rating for each competency using the 0-4 scale. Faculty may also include comments related
to each competency. At the end of this clinical evaluation tool, faculty should write summary comments and
document recommendations for further developmenUimprovement. The faculty who wrote the evaluation will
review it with the student and document the date of the meeting. The student should be provided with a copy of
the evaluation. Students will also be asked to complete a self-evaluation using the Lasater Tool. Clinical
Instructor~ are to present guidelines on these assessment tools at the start of every semester during the skills
orientation period
NOTE: In these competencies, client is defined as the recipient of professional nursing services and may be an
individual, family, or group.

References Used for Tool Development

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice.
Washington, DC: Author.
Cronenwett, L., Sherwood, G. , Bamsteiner J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D., & Warren, J. (2007). Quality and safety
education for nurses. Nursing Outlook, 55,122-131 .
Holaday, s., & Buckley, K. (2008). A standardize~ clinical e~aluatlon tool-kit: Improving nursing ~d~catlon and practice. In M. H. Oermann &
K. T. Heinrich (Eds.), Annual Review of Nursing Education, Vol. 6. New York: Springer Pubilsh!ng. . .
https:/twww.nmc.orq.uk/globalassets/sitedocuments/standards/nmc-standards-for-pre-reqlstrat1on-nurs1ng-educat10n.pdf

Expected Levels of Performance: BSN students must show steady improvement in accuracy, safety, and
efficiency, and will be expected to require less guidance in the clinical area as they progress in the program.
Rating Scale
QUALITY of PERFORMANCE
EXEMPLARY/ SELF-DIRECTED (4)
Almost Alwalr'.S Exhibits {>90'a of the time)
• clarity of focus on the client or system
• efficiency and organization
• accuracy, safety, and skillfulness
• initiative & eagerness to learn
• empathy and compassion

QUALITY of PERFORMANCE
ACCOMPLISHED/ SUPERVISED (3)
Very Often Exhibits (75% of the time)
• clarity of focus on the client or system
• efficiency and organ ization
• accuracy, safety, and skillfulness
• initiative & eagerness to learn
• empathy and compassion

QUALITY of PERFORMANCE
DEVELOPING / ASSISTED (2)
Often Exhibits (50% of the time)
• clarity of focus on the client or system
• efficiency and organization
• accuracy, safety, and skillfulness
• initiative & eagerness to learn
• empathy and compassion

QUALITY of PERFORMANCE
BEGINNING/ NOVICE (1)
Occaslonalll£ Exhibits (25% of the time)
• clarity of focus on the client or system • efficiency and organization
• accuracy, safety, and skillfulness • initiative & eagerness to learn
• empathy and compassion

QUALITY of PERFORMANCE
FAIL/ DEPENDENT (0)
Almost Never Exhibits (<10o/2 of the time)
• clarity of focus on the client or system • efficiency and organization
• accuracy, safety, and skillfulness • initiative & eagerness to learn
• empathy and compassion

1. Demonstrates professional behaviors PO 8, 10, 11, 13 {SCs: CHARACTER) RATING

4 3 2 1 0
a. Follows SISC College of Nursing, and hospital/agency policies
b. Practices w ithin the legal and ethical frameworks of nursinl!
c. Assumes accountabil ity for own actions and oractlces
d. Treats all individuals with dignity/respect and demonstrates cultural sensitivity
e. Protects client rights (privacy, autonomy, confidentiality)
f. Demonstrates Initiative In seeking learning opportunities and resources
Analyzes personal strengths and limitations and Incorporates constructive feedback for performance
g. Improvement
h. Maintains professional appearance

i. Maintains professional attitude and maintains professional behavior

j. Prepares ahead and arrives on time for clinical duty
k. Notifies faculty In a timely manner If he/she wlll be absent or late

I. Identifies situations In which assistance Is needed OR appropriately seeks assistance

CLINICAL INSTRUCTOR'S COMMENTS:

 RATING
2. Collects and analyzes comprehensive client data PO 1, 2 (SCs: COMPETENCY & COMMITMENT TO ACHIEVE)
4 3 2 1 0

a. Determines relevant Information needed

b. identifies appropriate sources for data collection
c. Uses correct techniques for assessment
d. Interprets laboratory/diagnostic test results
e. Incorporates data from client, family/support persons and health care team members
CLINICAL INSTRUCTOR'S COMMENTS:

RATING
3. Plans appropriate client care PO 1, 2, 3 (SCs: COMPETENCY, COMMITMENT TO ACHIEVE AND CREATIVITY)
4 3 2 1 0

a. Develops plan of care based on analysis of assessment data

b. Accurately determines priorities for care
c. Communicates priorities and rationale for decisions to Instructor
d. Considers needs/preferences of the client in planning care and identifies appropriate resources needed
e. Establishes realistic goals/expected outcomes
CLINICAL INSTRUCTOR'S COMMENTS:

RATING
4. Provides safe client-centered care PO 1, 2, 3, 4, 5, 6, 12 (SCs: CHARACTER, COMPETENCY & COMMITMENT TO
ACHIEVE)
(Safe Behavior Criteria: The student is required to practice professional nursing sofely in specific client-centered
situations with clinical supervision. Sofe behavior is defined os behavior which does not place the client or self and 4 3 2 1 0
other professional staff at risk of phys/col and/or psychosocial harm. The student is subject to receiving a Failure In
the course and to being dismissed from the program if safe behavior is not consistently demonstrated.)

a. Plans and Implements evidence-based Interventions that are congruent with assessment data
Considers client needs and preferences In providing care and takes the role of client advocate by acting
b. on their behalf and In their best Interest
c. Performs nursing skills and therapeutic procedures safely and competently

d. Follows principles of Infection control

e. Follows procedures for medication administration

Recognizes own limitations related to nursing skills or technologies and takes appropriate steps for
f. Improvement
fl , Takes appropriate steps to lmorove nursing skills and use of technologies

h. Creates a safe environment for client care

I. Demonstrates flexibility in adapting to changing client care situations

j. Reports abnormal data and changes In client condition to Instructor or appropriate health team member

CLINICAL INSTRUCTOR'S COMMENTS:

5. Engages in systematic and ongoing evaluation of the plan of care PO 6, 7,8 (SCs: COMPETENCY, RATING
COMMITMENT TO ACHIEVE & COLLABORATION)
4 3 2 1 0
a. Evaluat es nursing Interventions based on goals/expected outcomes
b. Analyzes client data for accuracy and completeness
C. Revises plan of care based on evaluation and consultation
d. Involves client, significant others, and health team members In evaluation process as relevant

CLINICAL INSTRUCTOR'S COMMENTS:

RATING
6. Applies knowledge relevant to client care PO 1, 2, 3, (SCS: COMPETENCY & COMMITMENT TO ACHIEVE)
4 3 2 1 0

a. Demonstrates initiative to obtain needed knowledge

b. Evaluates sources of data for appropriateness, usefulness, and accuracy
c. Integrates theo ry from nursing, natural and social sciences to enhance client care
Relates pathophysiology and epidemiology of disease(s) to clients' assessment findings, medications,
d.
laboratory and dia11nostic test resu lts, medical and nursing Interventions
e. Integrates concepts of health promotion and disease prevention Into client care
f. Identifies issues/problems in nursing practice that need to be improved
h. Evaluates nursing practices based on current research evidence

CLINICAL INSTRUCTOR'S COMMENTS:

RATING
7. Communicates effectively PO 5, 6, 7, 8 (SCs: CHARACTER, COMPETENCY & COLLABORATION)
4 3 2 1 0

a. Produces clear, le11allv accurate, timely, organized, and thorough record and documentation
b. Communicates therapeutically with clients utilizing verbal and nonverbal skills
c. Listens attentively and respectfully to others
d. Is actively involved In team building, fostering collegiality, and encouraging cooperation
e. contributes insight and helpful information to the health care team/group conferences
CLINICAL INSTRUCTOR'S COMMENTS:

8. Uses teach ing-learning process when providing individualized cllent/famlly/group education PO 1, 2, 7, 8, 12,
RATING
13 (5Cs: COMPETENCY, COMMITMENT TO ACHIEVE & CREATIVITY) 4 3 2 1 0

a. Assesses iearnln11 needs of clients, families, and groups

Assesses readiness fo r and barriers to learning and considers appropriate client characteristics In
b. teaching 1e.g., culture, age, developmental level, and educational level)
Develops an appropriate teaching plan for learner needs and specifies reasonable and appropriate
c.
outcome measures
d. Utilizes aooro orlate orlncloles of teaching/learning when lmolementinl! a teachln11 clan

e. Evaluates learner outcomes, provides feedback, and revises teaching plan as needed

CLINICAL INSTRUCTOR'S COMMENTS:

I . 9. Exhibits empathy & compassion to facllltate blo•psycho-soclal-splrltual health PO 11, 13 (SCs: CHARACTER, RATING
CREATIVITY & COLLABORATION) 4 3 2 1 0
Demonstrates sensitivity to cultural, moral, spiritual, and ethical beliefs of clients, families, peers, health
a. care
b. Incorporates empathy and compassion In all situations and client encounters
c. Protects the client's safety and privacy, and preserves human dignity while providing care
d.
Encourages family and/or significant others' participation In care as appropriate
Recogn izes barriers to care such as socioeconomic factors, environmental factors, and support systems
e.
and assists clients with coping and adaptation strategies

CLINICAL INSTRUCTOR'S COMMENTS:

Overall Instructor Comments: Instructor recommendations for further development/Improvement:

Name and Signature of Instructor: __________________

Part 2. LASATER CLINICAL JUDGMENT RUBRIC: Self-Evaluation Tool

Instructions: Students are to rate their clinical performance according to the 11 dimensions as exemplified by
the 5Cs. Honestly evaluate oneself using the designated rating scale as follows:

Exemplary: 91 %++ Accomplished: 87-90% Developing: 82-86% Beginning: <81%

Exemplary Accompllshed Developing Beginning

Dimension 91%+ 87-90" 82-86" <81"

Effective noticing involves: (5Cs: COMPETENCE & COMMITMENT TO ACHIEVE)

Focused observation Focuses observation Regularly observes Attempts to monitor a Confused by the
appropriately; regularly and monitors a variety variety of subjective clinical situation and
observes and monitors a of data, including both and objective data but the amount and kind of
wide variety of objective subjective and objective; is overwhelmed by the data; observation is not
and subjective data most useful infonnation array of data; focuses on organized and important
to uncover any useful is noticed; may miss the the most obvious data, data are missed, and/or
infonnation most subtle signs missing some important assessment errors are
infonnation made
\Rate:
Recognizing deviations Recognizes subtle Recognizes most Identifies obvious Focuses on one thing at
patterns and deviations obvious patterns and patterns and deviations, a time and misses most
from expected patterns
from expected patterns deviations in data and missing some important patterns and deviations
in data and uses these uses these to continually infonnation; unsure from expectations;
to guide the assessment assess how to continue the misses opportunities to
assessment refine the assessment

Rate:
Assertively seeks
infonnation to plan
intervention: carefully
lnfonnation seeking
collects useful subjective
data from observing
and interacting with the
patient and family
!Rate:
Effective interpreting involves: (5Cs: COMPETENCE)
Prioritizing data Focuses on the most
relevant and important
data useful for explaining
the patient's condition
Actively seeks subjective Makes limited efforts Is ineffective in seeking
infonnation about to seek additional infonnation; relies mostly
the patient's situation infonnation from the on objective data; has
patient and family; often difficulty interacting
from the patient and
family to support seems not to know what with the patient and
planning interventions; infonnation to seek family and fails to collect
occasionally does not and/or pursues unrelated important subjective
pursue important leads infonnatlon data
Generally focuses on the Makes an effort to Has difficulty focusing
most important data and prioritize data and focus and appears not to
seeks further relevant on the most important, know which data are
infonnation but also but also attends to less most important to the
may try to attend to less relevant or useful data diagnosis; attempts to
pertinent data attend to all available data

Making sense of data Even when facing
complex, conflicting, or
confusing data, is able to
(a) note and make sense
of patterns in the patient's
data, (b) compare these
with known patterns (from
the nursing knowledge
base, research, personal
experience, and intuition),
and (c) develop plans for
interventions that can be
justified in tenns of their
likelihood of success
In most situations, In simple, common, or
interprets the patient's familiar situations, is
data patterns and able to compare the
compares with known patient's data patterns
patterns to develop an
with those known and
intervention plan and
accompanying rationale; to develop or explain
the exceptions are rare intervention plans;
or in complicated cases has difficulty, however,
where it is appropriate with even moderately
to seek the guidance of difficult data or situations
a specialist or a more that are within the
experienced nurse expectations of students;
inappropriately requires
advice or assistance
Even in simple, common,
or familiar situations,
has difficulty interpreting
or making sense of
data; has trouble
distinguishing among
competing explanations
and appropriate
Interventions, requiring
assistance both in
diagnosing the problem
and developing an
Intervention

Effective responding involves: (5Cs: CHARACTER, CREATIVITY & COLLABORATION)

Calm, confident manner Assumes responsibility; Generally displays Is tentative in the Except in simple and
delegates team leadership and leader role; reassures routine situations,
assignments; assesses confidence and is able patients and families in is stressed and
patients and reassures to control or calm most routine and relatively disorganized, lacks
them and their families situations; may show simple situations, but control, makes patients
stress in particularly becomes stressed and and families anxious or
difficult or complex disorganized easily less able to cooperate
situations
IRate:
 Lasater Cllnlcal Judgment Rubric
Exemplary Accompllshed Developing Beginning
Dimension 91%+ 87-90% 82-86" <81"

Clear communication Communicates Generally communicates Shows some Has difficulty

effectively; explains
interventions; calms
and reassures patients
and families; directs and
involves team members,
explaining and giving
directions; checks for
understanding
&!.Jg_;_
Well-planned Interventions are
intervention/flexibility tailored for the individual
patient; monitors patient
progress closely and is
able lo adjust treatment
as indicated by patient
response
well; explains carefully
to patients; gives clear
directions to team; could
be more effective In
establishing rapport
Develops interventions
on the basis of relevant
patient data; monitors
progress regularly but
does not expect to have
to change treatments
communication ability
(e.g., giving directions);
communication with
patients, families, and
team members is
only partly successful;
displays caring but not
competence
Develops interventions
on the basis of the most
obvious data; monnors
progress but is unable
lo make adjustments as
indicated by the patient's
response
communicating;
explanations are
confusing; directions are
unclear or contradictory;
patients and families
are made confused or
anxious and are not
reassured
Focuses on developing
a single Intervention,
addressing a likely
solution, but nmay
be vague, confusing,
and/or incomplete; some
monnoring may occur

Being skillful Shows mastery of Displays proficiency in Is hesitant or ineffective Is unable to select and/
necessary nursing skills the use of most nursing in using nursing skills or perform nursing skills
skills; could improve
speed or accuracy

Effective reflecting involves: (SCs: COMMITMENT TO ACHIEVE & CHARACTER

Evaluation/self-analysis Independently evaluates Evaluates and analyzes Even when prompted, Even prompted
and analyzes personal personal clinical briefly verbalizes evaluations are brief,
clinical performance, performance with the most obvious cursory, and not used to
noting decision points, minimal prompting, evaluations; has difficulty Improve performance;
elaborating alternatives, primarily about major imagining alternative justifies personal
and accurately events or decisions; choices; is self-protective decisions and choices
evaluating choices key decision points in evaluating personal without evaluating them
against alternatives are identified, and choices
alternatives are
considered
l&!k
Commitment to Demonstrates Demonstrates a desire Demonstrates Appears uninterested in
improvement commitment to ongoing to improve nursing awareness of the need improving performance
improvement; reflects performance; reflects for ongoing improvement or is unable to do
on and crnically on and evaluates and makes some so; rarely reflects; is
evaluates nursing experiences; identifies effort to learn from uncritical of himself
experiences; accurately strengths and experience and improve or herself or overly
identifies strengths weaknesses; could performance but tends critical (given level of
and weaknesses and be more systematic in to state the obvious development); is unable
develops specific plans evaluating weaknesses and needs external to see flaws or need for
to eliminate weaknesses evaluation Improvement
l&,te:
C 2005, Kathie Lasater, EdD, RN. Developed from Tanner's (2006) Clinical JudQment Model

Average Rating: _ _ _ __
Comment(s) / Remark(s):

Student's Signature over Printed Name

Supervised by:

Cllnlcal Instructor
Attendance

Date/s of Absences Reason Remarks No. of Make-

up Duty

Date/s of Tardiness Reason Remarks No. of Make-

up Duty

Violation/s Remarks No. of Make-up

O~ty

Summary of Grades

Part 1. Clinical Evaluation Part 2. Lasater Clinical Judgement PCCR (20%) Quizzes, NCPs, Attendance
Tool (40%) Self- Evaluation (20%) etc (10%) (10%)

Final RLE Grade: _ _ _ _ _ _ __ Date:

--------
Signed by:

Name and Signature of Clinical Instructor

Checked and Reviewed by:

Name and Signature of Clinical Coordinator