Clinical Evaluation Tool Revised June 2017

Evaluator: Grigsby, Alicia (agrigsby1@usf.edu) Completed Date:11/03/2022

Evaluatee: Schaff, Heather(hschaff@usf.edu) Rotation:NUR4227.003F22.95581 11/2/2022

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in
learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and
requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them.

3-Minimal (Consider Level 3 Violation)

Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge
and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities.
Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory (Consider Level 2 Violation)

Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing
care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient.

1-Unsafe to Practice (Consider Level 1 Violation)

Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into
practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient.
Standard 1: Patient-Centered Care
1. Performs a comprehensive assessment including patient values, preferences, and needs.
2. Develops an individualized plan of care with a focus on the nursing process.
3. Provides care with sensitivity and respect for the diversity of the human experience.
4. Delivers care based on knowledge of pathophysiology and pharmacotherapy.
5. Identifies potential barriers to active involvement of patients in their own health care process.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

Student always completes her NPW. She fully engages with other students during post conference.

Standard 2: Teamwork and Collaboration

1. Demonstrates awareness of own strengths and limitations as a team member.
2. Initiates requests for help from other team members as appropriate.
3. Communicates effectively with patients, family members, and other members of the healthcare team.
4. Identifies potential complications related to handoffs or transitions of care.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

During clinical rounds the patients and family members are always complementing her care. She develops a strong rapport with patients.

Standard 3: Evidence-Based Practice and Quality Improvement

1. Utilizes evidence-based literature to support clinical decision making as demonstrated in written clinical assignments.
2. Differentiates clinical opinion from evidence-based practice to determine best clinical practice.
3. Promotes and practices quality, cost-effective delivery of care.
4. Identifies potential areas for quality improvement in the clinical setting.
5. Participates in measures to improve patient outcomes as appropriate.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

NPW demonstrates a clear picture of patient care and I am able to follow the plan.

Page 1 of 3
 Clinical Evaluation Tool Revised June 2017
Standard 4: Safety
1. Identifies strategies to reduce the risk of harm or poor patient outcomes in the delivery of care.
2. Delivers medication (as appropriate) in a timely and safe manner including understanding the specific indications for the medication
and potential side effects.
3. Communicates effectively between team members or to clinical faculty when giving patient report.
4. Uses appropriate resources to improve organization and/or time management.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

Student arrives on time during clinical and has everything prepared for the day. She writes down important medication before
administration and list each potential side effects and explains in great detail.
Standard 5: Informatics
1. Navigates the electronic health record where appropriate.
2. Documents clearly, concisely, and accurately in the electronic medical record where appropriate.
3. Protects confidentiality of all protected health information.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

Student comes in prepared and signs in the EMR. Documents a concise assessment during clinical and on her NPW.

Standard 6: Professionalism
1. Demonstrates core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice).
2. Maintains professional behavior and appearance.
3. Demonstrates expected behaviors and completes tasks in a timely manner.
4. Engages in self-evaluation and assumes responsibility for learning.
5. Arrives to clinical setting on time.
6. Demonstrates evidence of preparation for clinical learning experiences.
7. Maintains a positive attitude while interacting with patients, family members, faculty, peers, or members of the healthcare team.
8. Accepts individual responsibility for actions.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

Positive attitude towards patients and other students. She is always smiling and welcomes her assignments in clinical.

Levels of Practice Violations

Level 3 Violation
• Potential for unsafe practice
• Typically a single event or occurrence that presents minimal risk for patient harm
• Examples include but are not limited to being unprepared for clinical or a perceived disrespectful attitude.
• Intervention: Interaction with clinical instructor. Complete student contact form. Notify course coordinator.
Level 2 Violation
• Evidence of unsafe practice
• Pattern of behavior
• Examples include but are not limited to pattern of being unprepared for clinical, unable to organize patient report, continued inability to
describe indications for medications or interventions
• Intervention: Meet with clinical instructor. Notify course coordinator and program director. Academic Jeopardy Form with clear plan
for resolution of concerning behavior.
Level 1 Violation
• Unsafe practice with unacceptable risk for harm
• Examples include but are not limited to dishonesty, failure to change behaviors in response to feedback, physical or mental impairment
(intoxication or lack of sleep), violent behavior, breach of confidentiality, extreme anxiety, angry or unprofessional outburst.
• Intervention: Immediate removal from all clinical, lab, and simulation activities. Notify course coordinator and program director.

N/A

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 Clinical Evaluation Tool Revised June 2017
Comments: I have enjoyed working with her as a student.

Schaff, Heather reviewed the above evaluation on 11/13/2022 7:49:00PM.

Page 3 of 3
 Clinical Evaluation Tool
Evaluator: White, Sarah (swhite29@usf.edu) Completed Date:04/15/2023
Evaluatee: Schaff, Heather(hschaff@usf.edu) Rotation:NUR4635L_WHITE_spring2023

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in
learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and
requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them.

3-Minimal
Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge
and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities.
Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory
Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing
care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient.

1-Unsafe to Practice
Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into
practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient.
Course

Answer: NUR 4635L PUBLIC HEALTH NURSING CLINICAL

Semester

Answer: Spring

Year

2023

Select Evaluation Type

Answer: Formative A summative

-

Standard 1: Patient-Centered Care

1. Performs a comprehensive assessment including patient values, preferences, and needs.
2. Develops an individualized plan of care with a focus on the nursing process.
3. Provides care with sensitivity and respect for the diversity of the human experience.
4. Delivers care based on knowledge of pathophysiology and pharmacotherapy.
5. Identifies potential barriers to active involvement of patients in their own health care process.

Answer: 4 Satisfactory: Meets Standards

Standard 2: Teamwork and Collaboration

1. Demonstrates awareness of own strengths and limitations as a team member.
2. Initiates requests for help from other team members as appropriate.
3. Communicates effectively with patients, family members, and other members of the healthcare team.
4. Identifies potential complications related to handoffs or transitions of care.

Answer: 4 Satisfactory: Meets Standards

Page 1 of 2
 Clinical Evaluation Tool
Standard 3: Evidence-Based Practice and Quality Improvement
1. Utilizes evidence-based literature to support clinical decision making as demonstrated in written clinical assignments.
2. Differentiates clinical opinion from evidence-based practice to determine best clinical practice.
3. Promotes and practices quality, cost-effective delivery of care.
4. Identifies potential areas for quality improvement in the clinical setting.
5. Participates in measures to improve patient outcomes as appropriate.

Answer: 4 Satisfactory: Meets Standards

Standard 4: Safety
1. Identifies strategies to reduce the risk of harm or poor patient outcomes in the delivery of care.
2. Delivers medication (as appropriate) in a timely and safe manner including understanding the specific indications for the medication
and potential side effects.
3. Communicates effectively between team members or to clinical faculty when giving patient report.
4. Uses appropriate resources to improve organization and/or time management.

Answer: 4 Satisfactory: Meets Standards

Standard 5: Informatics
1. Navigates the electronic health record where appropriate.
2. Documents clearly, concisely, and accurately in the electronic medical record where appropriate.
3. Protects confidentiality of all protected health information.

Answer: 4 Satisfactory: Meets Standards

Standard 6: Professionalism
1. Demonstrates core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice).
2. Maintains professional behavior and appearance.
3. Demonstrates expected behaviors and completes tasks in a timely manner.
4. Engages in self-evaluation and assumes responsibility for learning.
5. Arrives to clinical setting on time.
6. Demonstrates evidence of preparation for clinical learning experiences.
7. Maintains a positive attitude while interacting with patients, family members, faculty, peers, or members of the healthcare team.
8. Accepts individual responsibility for actions.

Answer: 4 Satisfactory: Meets Standards

Schaff, Heather reviewed the above evaluation on 4/16/2023 9:32:00PM.

Page 2 of 2
 Clinical Evaluation Tool Revised June 2017
Evaluator: Radford, Cristina (cpenzabe@usf.edu) Completed Date:03/16/2022
Evaluatee: Schaff, Heather(hschaff@usf.edu) Rotation:NUR4467L SJS UD JHAC 3/12/2022

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in
learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and
requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them.

3-Minimal (Consider Level 3 Violation)

Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge
and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities.
Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory (Consider Level 2 Violation)

Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing
care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient.

1-Unsafe to Practice (Consider Level 1 Violation)

Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into
practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient.
Standard 1: Patient-Centered Care
1. Performs a comprehensive assessment including patient values, preferences, and needs.
2. Develops an individualized plan of care with a focus on the nursing process.
3. Provides care with sensitivity and respect for the diversity of the human experience.
4. Delivers care based on knowledge of pathophysiology and pharmacotherapy.
5. Identifies potential barriers to active involvement of patients in their own health care process.

Answer: 4 Satisfactory: Meets Standards

Standard 2: Teamwork and Collaboration

1. Demonstrates awareness of own strengths and limitations as a team member.
2. Initiates requests for help from other team members as appropriate.
3. Communicates effectively with patients, family members, and other members of the healthcare team.
4. Identifies potential complications related to handoffs or transitions of care.

Answer: 4 Satisfactory: Meets Standards

Standard 3: Evidence-Based Practice and Quality Improvement

1. Utilizes evidence-based literature to support clinical decision making as demonstrated in written clinical assignments.
2. Differentiates clinical opinion from evidence-based practice to determine best clinical practice.
3. Promotes and practices quality, cost-effective delivery of care.
4. Identifies potential areas for quality improvement in the clinical setting.
5. Participates in measures to improve patient outcomes as appropriate.

Answer: 4 Satisfactory: Meets Standards

Standard 4: Safety
1. Identifies strategies to reduce the risk of harm or poor patient outcomes in the delivery of care.
2. Delivers medication (as appropriate) in a timely and safe manner including understanding the specific indications for the medication
and potential side effects.
3. Communicates effectively between team members or to clinical faculty when giving patient report.
4. Uses appropriate resources to improve organization and/or time management.

Answer: 4 Satisfactory: Meets Standards

Page 1 of 2
 Clinical Evaluation Tool Revised June 2017
Standard 5: Informatics
1. Navigates the electronic health record where appropriate.
2. Documents clearly, concisely, and accurately in the electronic medical record where appropriate.
3. Protects confidentiality of all protected health information.

Answer: 4 Satisfactory: Meets Standards

Standard 6: Professionalism
1. Demonstrates core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice).
2. Maintains professional behavior and appearance.
3. Demonstrates expected behaviors and completes tasks in a timely manner.
4. Engages in self-evaluation and assumes responsibility for learning.
5. Arrives to clinical setting on time.
6. Demonstrates evidence of preparation for clinical learning experiences.
7. Maintains a positive attitude while interacting with patients, family members, faculty, peers, or members of the healthcare team.
8. Accepts individual responsibility for actions.

Answer: 4 Satisfactory: Meets Standards

Levels of Practice Violations

Level 3 Violation
• Potential for unsafe practice
• Typically a single event or occurrence that presents minimal risk for patient harm
• Examples include but are not limited to being unprepared for clinical or a perceived disrespectful attitude.
• Intervention: Interaction with clinical instructor. Complete student contact form. Notify course coordinator.
Level 2 Violation
• Evidence of unsafe practice
• Pattern of behavior
• Examples include but are not limited to pattern of being unprepared for clinical, unable to organize patient report, continued inability to
describe indications for medications or interventions
• Intervention: Meet with clinical instructor. Notify course coordinator and program director. Academic Jeopardy Form with clear plan
for resolution of concerning behavior.
Level 1 Violation
• Unsafe practice with unacceptable risk for harm
• Examples include but are not limited to dishonesty, failure to change behaviors in response to feedback, physical or mental impairment
(intoxication or lack of sleep), violent behavior, breach of confidentiality, extreme anxiety, angry or unprofessional outburst.
• Intervention: Immediate removal from all clinical, lab, and simulation activities. Notify course coordinator and program director.

Does not apply to this student

Comments: Heather did a great job this rotation.

Schaff, Heather reviewed the above evaluation on 4/20/2022 11:03:00AM and has provided the following comment:

Thank you! I loved working with you :)

Page 2 of 2
 Clinical Evaluation Tool Revised June 2017
Evaluator: Duff, Carla (duffcm@usf.edu) Completed Date:05/03/2022
Evaluatee: Schaff, Heather(hschaff@usf.edu) Rotation: 5/3/2022

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in
learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and
requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them.

3-Minimal (Consider Level 3 Violation)

Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge
and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities.
Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory (Consider Level 2 Violation)

Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing
care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient.

1-Unsafe to Practice (Consider Level 1 Violation)

Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into
practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient.
Standard 1: Patient-Centered Care
1. Performs a comprehensive assessment including patient values, preferences, and needs.
2. Develops an individualized plan of care with a focus on the nursing process.
3. Provides care with sensitivity and respect for the diversity of the human experience.
4. Delivers care based on knowledge of pathophysiology and pharmacotherapy.
5. Identifies potential barriers to active involvement of patients in their own health care process.

Answer: 4 Satisfactory: Meets Standards

Standard 2: Teamwork and Collaboration

1. Demonstrates awareness of own strengths and limitations as a team member.
2. Initiates requests for help from other team members as appropriate.
3. Communicates effectively with patients, family members, and other members of the healthcare team.
4. Identifies potential complications related to handoffs or transitions of care.

Answer: 4 Satisfactory: Meets Standards

Standard 3: Evidence-Based Practice and Quality Improvement

1. Utilizes evidence-based literature to support clinical decision making as demonstrated in written clinical assignments.
2. Differentiates clinical opinion from evidence-based practice to determine best clinical practice.
3. Promotes and practices quality, cost-effective delivery of care.
4. Identifies potential areas for quality improvement in the clinical setting.
5. Participates in measures to improve patient outcomes as appropriate.

Answer: 4 Satisfactory: Meets Standards

Standard 4: Safety
1. Identifies strategies to reduce the risk of harm or poor patient outcomes in the delivery of care.
2. Delivers medication (as appropriate) in a timely and safe manner including understanding the specific indications for the medication
and potential side effects.
3. Communicates effectively between team members or to clinical faculty when giving patient report.
4. Uses appropriate resources to improve organization and/or time management.

Answer: 4 Satisfactory: Meets Standards

Page 1 of 2
 Clinical Evaluation Tool Revised June 2017
Standard 5: Informatics
1. Navigates the electronic health record where appropriate.
2. Documents clearly, concisely, and accurately in the electronic medical record where appropriate.
3. Protects confidentiality of all protected health information.

Answer: 4 Satisfactory: Meets Standards

Standard 6: Professionalism
1. Demonstrates core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice).
2. Maintains professional behavior and appearance.
3. Demonstrates expected behaviors and completes tasks in a timely manner.
4. Engages in self-evaluation and assumes responsibility for learning.
5. Arrives to clinical setting on time.
6. Demonstrates evidence of preparation for clinical learning experiences.
7. Maintains a positive attitude while interacting with patients, family members, faculty, peers, or members of the healthcare team.
8. Accepts individual responsibility for actions.

Answer: 4 Satisfactory: Meets Standards

Levels of Practice Violations

Level 3 Violation
• Potential for unsafe practice
• Typically a single event or occurrence that presents minimal risk for patient harm
• Examples include but are not limited to being unprepared for clinical or a perceived disrespectful attitude.
• Intervention: Interaction with clinical instructor. Complete student contact form. Notify course coordinator.
Level 2 Violation
• Evidence of unsafe practice
• Pattern of behavior
• Examples include but are not limited to pattern of being unprepared for clinical, unable to organize patient report, continued inability to
describe indications for medications or interventions
• Intervention: Meet with clinical instructor. Notify course coordinator and program director. Academic Jeopardy Form with clear plan
for resolution of concerning behavior.
Level 1 Violation
• Unsafe practice with unacceptable risk for harm
• Examples include but are not limited to dishonesty, failure to change behaviors in response to feedback, physical or mental impairment
(intoxication or lack of sleep), violent behavior, breach of confidentiality, extreme anxiety, angry or unprofessional outburst.
• Intervention: Immediate removal from all clinical, lab, and simulation activities. Notify course coordinator and program director.

N/A

Comments: Heather demonstrated superb assessment skills with newborns.

She was proficient at passing medications.

Schaff, Heather reviewed the above evaluation on 5/7/2022 4:10:00PM and has provided the following comment:

Thank you!

Page 2 of 2
 Clinical Evaluation Tool Revised June 2017
Evaluator: Ambroise, Christina (cedoizin@usf.edu) Completed Date:07/31/2022
Evaluatee: Schaff, Heather(hschaff@usf.edu) Rotation:NUR 4535L 108U22.56011 7/31/2022

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in
learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and
requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them.

3-Minimal (Consider Level 3 Violation)

Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge
and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities.
Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory (Consider Level 2 Violation)

Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing
care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient.

1-Unsafe to Practice (Consider Level 1 Violation)

Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into
practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient.
Standard 1: Patient-Centered Care
1. Performs a comprehensive assessment including patient values, preferences, and needs.
2. Develops an individualized plan of care with a focus on the nursing process.
3. Provides care with sensitivity and respect for the diversity of the human experience.
4. Delivers care based on knowledge of pathophysiology and pharmacotherapy.
5. Identifies potential barriers to active involvement of patients in their own health care process.

Answer: 4 Satisfactory: Meets Standards

Standard 2: Teamwork and Collaboration

1. Demonstrates awareness of own strengths and limitations as a team member.
2. Initiates requests for help from other team members as appropriate.
3. Communicates effectively with patients, family members, and other members of the healthcare team.
4. Identifies potential complications related to handoffs or transitions of care.

Answer: 4 Satisfactory: Meets Standards

Standard 3: Evidence-Based Practice and Quality Improvement

1. Utilizes evidence-based literature to support clinical decision making as demonstrated in written clinical assignments.
2. Differentiates clinical opinion from evidence-based practice to determine best clinical practice.
3. Promotes and practices quality, cost-effective delivery of care.
4. Identifies potential areas for quality improvement in the clinical setting.
5. Participates in measures to improve patient outcomes as appropriate.

Answer: 4 Satisfactory: Meets Standards

Standard 4: Safety
1. Identifies strategies to reduce the risk of harm or poor patient outcomes in the delivery of care.
2. Delivers medication (as appropriate) in a timely and safe manner including understanding the specific indications for the medication
and potential side effects.
3. Communicates effectively between team members or to clinical faculty when giving patient report.
4. Uses appropriate resources to improve organization and/or time management.

Answer: 4 Satisfactory: Meets Standards

Page 1 of 2
 Clinical Evaluation Tool Revised June 2017
Standard 5: Informatics
1. Navigates the electronic health record where appropriate.
2. Documents clearly, concisely, and accurately in the electronic medical record where appropriate.
3. Protects confidentiality of all protected health information.

Answer: 4 Satisfactory: Meets Standards

Standard 6: Professionalism
1. Demonstrates core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice).
2. Maintains professional behavior and appearance.
3. Demonstrates expected behaviors and completes tasks in a timely manner.
4. Engages in self-evaluation and assumes responsibility for learning.
5. Arrives to clinical setting on time.
6. Demonstrates evidence of preparation for clinical learning experiences.
7. Maintains a positive attitude while interacting with patients, family members, faculty, peers, or members of the healthcare team.
8. Accepts individual responsibility for actions.

Answer: 4 Satisfactory: Meets Standards

Levels of Practice Violations

Level 3 Violation
• Potential for unsafe practice
• Typically a single event or occurrence that presents minimal risk for patient harm
• Examples include but are not limited to being unprepared for clinical or a perceived disrespectful attitude.
• Intervention: Interaction with clinical instructor. Complete student contact form. Notify course coordinator.
Level 2 Violation
• Evidence of unsafe practice
• Pattern of behavior
• Examples include but are not limited to pattern of being unprepared for clinical, unable to organize patient report, continued inability to
describe indications for medications or interventions
• Intervention: Meet with clinical instructor. Notify course coordinator and program director. Academic Jeopardy Form with clear plan
for resolution of concerning behavior.
Level 1 Violation
• Unsafe practice with unacceptable risk for harm
• Examples include but are not limited to dishonesty, failure to change behaviors in response to feedback, physical or mental impairment
(intoxication or lack of sleep), violent behavior, breach of confidentiality, extreme anxiety, angry or unprofessional outburst.
• Intervention: Immediate removal from all clinical, lab, and simulation activities. Notify course coordinator and program director.

None noted during clinical visits

Schaff, Heather reviewed the above evaluation on 8/1/2022 9:32:00AM.

Page 2 of 2
 Clinical Evaluation Tool Revised June 2017
Evaluator: Arzt, Megan (marzt@usf.edu) Completed Date:05/05/2022
Evaluatee: Schaff, Heather(hschaff@usf.edu) Rotation:NUR 3225L STJS UD Section 108 5/5/2022

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in
learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and
requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them.

3-Minimal (Consider Level 3 Violation)

Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge
and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities.
Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory (Consider Level 2 Violation)

Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing
care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient.

1-Unsafe to Practice (Consider Level 1 Violation)

Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into
practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient.
Standard 1: Patient-Centered Care
1. Performs a comprehensive assessment including patient values, preferences, and needs.
2. Develops an individualized plan of care with a focus on the nursing process.
3. Provides care with sensitivity and respect for the diversity of the human experience.
4. Delivers care based on knowledge of pathophysiology and pharmacotherapy.
5. Identifies potential barriers to active involvement of patients in their own health care process.

Answer: 4 Satisfactory: Meets Standards

Standard 2: Teamwork and Collaboration

1. Demonstrates awareness of own strengths and limitations as a team member.
2. Initiates requests for help from other team members as appropriate.
3. Communicates effectively with patients, family members, and other members of the healthcare team.
4. Identifies potential complications related to handoffs or transitions of care.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

Heather is a team player, consistently and tirelessly working to assist her patients, peers, and patients.

Standard 3: Evidence-Based Practice and Quality Improvement

1. Utilizes evidence-based literature to support clinical decision making as demonstrated in written clinical assignments.
2. Differentiates clinical opinion from evidence-based practice to determine best clinical practice.
3. Promotes and practices quality, cost-effective delivery of care.
4. Identifies potential areas for quality improvement in the clinical setting.
5. Participates in measures to improve patient outcomes as appropriate.

Answer: 4 Satisfactory: Meets Standards

Page 1 of 2
 Clinical Evaluation Tool Revised June 2017
Standard 4: Safety
1. Identifies strategies to reduce the risk of harm or poor patient outcomes in the delivery of care.
2. Delivers medication (as appropriate) in a timely and safe manner including understanding the specific indications for the medication
and potential side effects.
3. Communicates effectively between team members or to clinical faculty when giving patient report.
4. Uses appropriate resources to improve organization and/or time management.

Answer: 4 Satisfactory: Meets Standards

Standard 5: Informatics
1. Navigates the electronic health record where appropriate.
2. Documents clearly, concisely, and accurately in the electronic medical record where appropriate.
3. Protects confidentiality of all protected health information.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

Heather documents clearly and concisely charting her patients' assessments, both on the electronic record and her NPW. There was a day
where Heather was delayed due to a number of circumstances and she was successful in completing her work accurately, even ahead of
her classmates.
Standard 6: Professionalism
1. Demonstrates core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice).
2. Maintains professional behavior and appearance.
3. Demonstrates expected behaviors and completes tasks in a timely manner.
4. Engages in self-evaluation and assumes responsibility for learning.
5. Arrives to clinical setting on time.
6. Demonstrates evidence of preparation for clinical learning experiences.
7. Maintains a positive attitude while interacting with patients, family members, faculty, peers, or members of the healthcare team.
8. Accepts individual responsibility for actions.

Answer: 4 Satisfactory: Meets Standards

Levels of Practice Violations

Level 3 Violation
• Potential for unsafe practice
• Typically a single event or occurrence that presents minimal risk for patient harm
• Examples include but are not limited to being unprepared for clinical or a perceived disrespectful attitude.
• Intervention: Interaction with clinical instructor. Complete student contact form. Notify course coordinator.
Level 2 Violation
• Evidence of unsafe practice
• Pattern of behavior
• Examples include but are not limited to pattern of being unprepared for clinical, unable to organize patient report, continued inability to
describe indications for medications or interventions
• Intervention: Meet with clinical instructor. Notify course coordinator and program director. Academic Jeopardy Form with clear plan
for resolution of concerning behavior.
Level 1 Violation
• Unsafe practice with unacceptable risk for harm
• Examples include but are not limited to dishonesty, failure to change behaviors in response to feedback, physical or mental impairment
(intoxication or lack of sleep), violent behavior, breach of confidentiality, extreme anxiety, angry or unprofessional outburst.
• Intervention: Immediate removal from all clinical, lab, and simulation activities. Notify course coordinator and program director.

n/a

Comments: Heather works well with her patients and with the nurses she is assigned to shadow. She is the USF SJS " Energizer Bunny,"
always moving while helping her patients and others.

Schaff, Heather reviewed the above evaluation on 5/7/2022 4:10:00PM and has provided the following comment:

Thank you Megan! I appreciate the kind words, you have been a blessing this semester. I hope to have you again!

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 Clinical Evaluation Tool Revised June 2017
Evaluator: Smith, Eric (ecsmith3@usf.edu) Completed Date:10/31/2021
Evaluatee: Schaff, Heather(hschaff@usf.edu) Rotation:NUR 3026L SFB Section 108F21 10/30/2021

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in
learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and
requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them.

3-Minimal (Consider Level 3 Violation)

Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge
and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities.
Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory (Consider Level 2 Violation)

Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing
care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient.

1-Unsafe to Practice (Consider Level 1 Violation)

Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into
practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient.
Standard 1: Patient-Centered Care
1. Performs a comprehensive assessment including patient values, preferences, and needs.
2. Develops an individualized plan of care with a focus on the nursing process.
3. Provides care with sensitivity and respect for the diversity of the human experience.
4. Delivers care based on knowledge of pathophysiology and pharmacotherapy.
5. Identifies potential barriers to active involvement of patients in their own health care process.

Answer: 4 Satisfactory: Meets Standards

Heather is doing well with her comprehensive assessment and continues to improve with each week. She has been able to develop an
appropriate plan of care and she provides care with sensitivity and respect.
Standard 2: Teamwork and Collaboration
1. Demonstrates awareness of own strengths and limitations as a team member.
2. Initiates requests for help from other team members as appropriate.
3. Communicates effectively with patients, family members, and other members of the healthcare team.
4. Identifies potential complications related to handoffs or transitions of care.

Answer: 4 Satisfactory: Meets Standards

Heather is self aware of her areas of strength and where she could improve. She actively seeks out ways to improve on those areas that
she feels she can do better. She has had no issues in seeking help/answers from the appropriate staff when she is unsure of something.
Her communication with staff is clear and concise.
Standard 3: Evidence-Based Practice and Quality Improvement
1. Utilizes evidence-based literature to support clinical decision making as demonstrated in written clinical assignments.
2. Differentiates clinical opinion from evidence-based practice to determine best clinical practice.
3. Promotes and practices quality, cost-effective delivery of care.
4. Identifies potential areas for quality improvement in the clinical setting.
5. Participates in measures to improve patient outcomes as appropriate.

Answer: 4 Satisfactory: Meets Standards

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 Clinical Evaluation Tool Revised June 2017
Standard 4: Safety
1. Identifies strategies to reduce the risk of harm or poor patient outcomes in the delivery of care.
2. Delivers medication (as appropriate) in a timely and safe manner including understanding the specific indications for the medication
and potential side effects.
3. Communicates effectively between team members or to clinical faculty when giving patient report.
4. Uses appropriate resources to improve organization and/or time management.

Answer: 4 Satisfactory: Meets Standards

Heather is able to communicate effectively with the nursing staff and patients. She is able to clearly and concisely give patient report to
clinical instructor leaving little room for question as to why the patient is there or what is happening/planned for them.
Standard 5: Informatics
1. Navigates the electronic health record where appropriate.
2. Documents clearly, concisely, and accurately in the electronic medical record where appropriate.
3. Protects confidentiality of all protected health information.

Answer: 4 Satisfactory: Meets Standards

Heather has shown she is able to effectively navigate the EMR and clearly document her physical exam. Heather takes care to protect
patient confidentiality during clinicals and when using a patient for a clinical assignment demonstrating that she understands the
importance.
Standard 6: Professionalism
1. Demonstrates core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice).
2. Maintains professional behavior and appearance.
3. Demonstrates expected behaviors and completes tasks in a timely manner.
4. Engages in self-evaluation and assumes responsibility for learning.
5. Arrives to clinical setting on time.
6. Demonstrates evidence of preparation for clinical learning experiences.
7. Maintains a positive attitude while interacting with patients, family members, faculty, peers, or members of the healthcare team.
8. Accepts individual responsibility for actions.

Answer: 4 Satisfactory: Meets Standards

Heather always demonstrates core professional values when in the clinical setting. She maintains a professional appearance, is always in
full uniform and arrives to clinical on time. She has demonstrated that she is able to complete assigned tasks in a timely manner and she
engages in self evaluation of her strengths and limitations. She always has a positive attitude when interacting with staff, families and
clinical instructor.
Levels of Practice Violations
Level 3 Violation
• Potential for unsafe practice
• Typically a single event or occurrence that presents minimal risk for patient harm
• Examples include but are not limited to being unprepared for clinical or a perceived disrespectful attitude.
• Intervention: Interaction with clinical instructor. Complete student contact form. Notify course coordinator.
Level 2 Violation
• Evidence of unsafe practice
• Pattern of behavior
• Examples include but are not limited to pattern of being unprepared for clinical, unable to organize patient report, continued inability to
describe indications for medications or interventions
• Intervention: Meet with clinical instructor. Notify course coordinator and program director. Academic Jeopardy Form with clear plan
for resolution of concerning behavior.
Level 1 Violation
• Unsafe practice with unacceptable risk for harm
• Examples include but are not limited to dishonesty, failure to change behaviors in response to feedback, physical or mental impairment
(intoxication or lack of sleep), violent behavior, breach of confidentiality, extreme anxiety, angry or unprofessional outburst.
• Intervention: Immediate removal from all clinical, lab, and simulation activities. Notify course coordinator and program director.

N/A

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 Clinical Evaluation Tool Revised June 2017

Schaff, Heather reviewed the above evaluation on 10/31/2021 9:58:00PM.

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