Carroll Community College

Division of STEM, Nursing and Allied Health

Department of Nursing
NURS 140/233
Student Clinical Performance Evaluation - Summative
Student___________ Date (Term/Year)_______ Location___________ Faculty______________
S = Satisfactory
N = Needs Improvement
U = Unsatisfactory
(*) Denotes critical behaviors.
Students who meet any of the following criteria will be given a remediation plan and may be placed on probation.
Failure to progress in these areas may result in failure of the course.
- One unsatisfactory grade in a critical behavior
- Two needs improvements in a critical behavior
- Two unsatisfactory grades in a non-critical behavior
- Four needs improvements in non-critical behaviors
Integrating Concept: Context and Environment
Outcome 1: Identifies policies, procedures, safety concerns, patient characteristics, and
Student
teamwork within the organizational structure, with assistance. (PO/RNLG 2: Nursing Judgment,
Self-Eval
PO/RNLG 4: Spirit of Inquiry)
S/N/U
*Maintains ethical accountability for nursing practice in accordance with the ANA Code of Ethics.
S
*Maintains legal accountability for nursing practice in accordance with the Maryland Nurse Practice Act.
S
*Adheres to HIPAA guidelines regarding patient confidentiality.
S
Demonstrates the role of the nurse as patient advocate.
S
Integrating Concept: Knowledge and Science
Outcome 2: Identifies knowledge from nursing science and allied health disciplines to begin
Student
designing and implementing patient centered care for individuals, families, and communities, with Self-Eval
assistance. (PO/RNLG: 2 Nursing Judgment, PO/RNLG: 4 Spirit of Inquiry)
S/N/U
Collects evidence related to clinical practice from appropriate resources.
S
Integrates knowledge of evidence based theory from nursing and other disciplines to plan care.
S
Demonstrates accurate and holistic patient assessment skills.
S
Establishes appropriate nursing diagnoses based on patient assessment.
S
Determines patient specific etiology related to nursing diagnoses.
S
Determines patient specific signs and symptoms related to nursing diagnoses
S
Determines patient specific outcomes for nursing diagnoses.
S
Determines patient specific interventions for nursing diagnoses and outcome(s).
S
Implements care according to established plan and desired outcomes.
S
Evaluates patient response to care and revises plan as needed.
S
Integrating Concept: Personal and Professional Development
Outcome 3: Identifies the need for the lifelong process of learning nursing skills, values, and
behaviors, with assistance. (PO/RNLG: 3 Professional Identity, PO/RNLG: 4 Spirit of Inquiry)
Discusses patients plan of care with instructor.
Completes assignments as required and submits on time
Organizes time efficiently.
Demonstrates professional appearance and demeanor.
Engages in self-reflection and communicates learning needs to instructor.
Integrating Concept: Quality and Safety
Outcome 4: Identifies knowledge from nursing science and allied health disciplines to begin
providing competent care based on current standards of practice to minimize risk of harm to all
members of the health care system through system effectiveness and individual practice, with
assistance. (PO/RNLG: 1 Human Flourishing, PO/RNLG 2: Nursing Judgment, PO/RNLG 4: Spirit
of Inquiry)
*Provides safe care according to established standards of nursing practice.
Prioritizes patient care based on assessment.
Readily incorporates technology into clinical practice.
*Observes infection control precautions.
Demonstrates accountability and responsibility for own actions and attitudes.
*Demonstrates knowledge of medications for assigned patients.
*Administers medication safely using six rights of medication administration.
Integrating Concept: Relationship Centered Care
N140_N233 Clinical Eval 4/15/2016

Instructor
Eval of
Student

S/N/U
S
S
S
S
Instructor
Eval of
Student

S/N/U
S
S
S
S
S
S
S
S
S
S

Student
Self-Eval

Instructor
Eval of
Student

S/N/U
S
S
S
S
S

S/N/U
S
S
S
S
S

Student
Self-Eval

Instructor
Eval of
Student

S/N/U
S
S
S
S
S
S
S

S/N/U
S
S
S
S
S
S
S

Student
Self-Eval

Instructor
Eval of

Carroll Community College

Division of STEM, Nursing and Allied Health
Department of Nursing
NURS 140/233
Outcome 5: Recognizes that nursing is part of a collaborative interdisciplinary team which
provides holistic care to individual, family, community, and team relationships through the use of
therapeutic communication, with assistance. (PO/RNLG: 1 Human Flourishing, PO/RNLG: 3
Professional Identity)
Demonstrates ability to develop and maintain therapeutic relationships with diverse populations.
*Respects patients rights with regard to their dignity and human worth.
Identifies patient/family health education needs and implements patient teaching.
Documents patient care accurately and in a timely manner using the written or electronic health record.
Applies therapeutic communications skills.
Integrating Concept: Teamwork
Outcome 6: Recognizes the importance of effective communication and mutual respect when
working with all members of the health care team, with assistance. (PO/RNLG: 3 Professional
Identity)
Demonstrates initiative in assisting peers and health care team members in the clinical setting.
Seeks input from patient, instructor, peers, and healthcare team in the delivery of patient care.
*Updates instructor and healthcare team regarding changes in the patients condition in a timely manner.
Demonstrates professional communication skills using SBAR.
Participates actively in all aspects of the clinical experience.
Student Reflection- Looking back on the rotation:

Student

S/N/U
S
S
S
S

S/N/U
S
S
S
S
S

Student
Self-Eval

Instructor
Eval of
Student

S/N/U
S
S
S
S
S

S/N/U
S
S
S
S
S

How have you grown as a nurse? Please explain and use specific examples.
I gave my very first IM shot, and also put my first straight cath in a little boy.

Do you have any continuing concerns about your performance? Please explain.
I could use more confidence in myself when doing certain tasks.

Faculty Comments/ Student Learning Goals (**If an item was identified as N or U, narrative comments are necessary to
clarify student performance**)
Brooke showed confidence and professionalism when interacting with families and staff. When given the opportunity to do skills
she has only practiced at school (IM injections, catheterizing an infant) and new skills (cleaning wounds/lacerations), she
entered the room in a way that the families had complete trust in her abilities and she performed them well. She had multiple
opportunities to complete thorough assessments and was able to identify abnormalities such as the different advantageous
breath sounds. Medications were given accurately utilizing the 6 rights.
When given case scenarios, Brooke actively participated in evaluating labs, discussing possible diagnoses and planning
appropriate plan of care.

Student Signature:
Instructor Signature:

Brooke

Edens

Theresa Breitenbach, RNC, BSN

N140_N233 Clinical Eval 4/15/2016

Date: 10/3/14
Date: 10/3/14