Clinical Evaluation Form
Student Name: Xiao En Wang Course: NU 207
Student ID:142380 Semester: Spring 2023
Clinical Competencies Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Knowledge for Nursing Practice: 0 1 1 2 2 2
Incorporates classroom knowledge into an
understanding of why treatments are ordered and
when they should be administered, clarified, or
withheld
Person-Centered Care: 0 1 2 2 3 3
Acts as a compassionate and empathetic patient
advocate to develop, implement, and evaluate plans of
care in partnership with the patient
Population Health: 1 1 2 2 2 3
Provides care that is appropriate for developmental
stage, culture, socioeconomic status, and education
level
Scholarship for the Nursing Discipline: 0 1 2 2 1 2
Compares personal and local practice with best
evidence to identify ways to improve nursing care
Quality and Safety: 0 1 1 2 2 2
Identifies when safety and quality standards are not
met by self or others and responds appropriately
Interprofessional Partnerships: 0 1 2 2 2 3
Communicates and works appropriately with
members of the healthcare team
Informatics and Healthcare Technology: 1 1 1 2 2 2
Demonstrates effective and appropriate use of clinical
technologies while maintaining security, privacy, and
safety
Professionalism: 1 1 3 2 3 3
Demonstrates civility, honesty, integrity, personal
responsibility, and respect for patient rights and
dignity
Personal, Professional, and Leadership 1 1 3 2 2 3
Development:
Commits to personal and professional development by
acting on feedback, reflecting on personal practice,
seeking guidance and learning opportunities, and
working toward self-efficacy.
DATE 2/7 2/14 2/21 2/28 3/14 3/21 1/31
INSTRUCTOR INITIALS HG TS OW HG OW AR OW
SCORING:
Ineffective Novice Developing Proficient Skillful Expert
0 points 1 point 2 points 3 points 4 points 5 points
Behaviors are Behaviors are seen Behaviors are seen Behaviors are seen Behaviors are seen Mastery of
never displayed some of the time often, guidance more often than the majority of the behavior, displays
but generally only needed in decision- not, guidance time, displays sound clinical
with prompting/ making 25-50% of needed in decision- independent reasoning with no
guidance the time making < 25% of clinical reasoning guidance needed
the time with minimal
guidance needed
Day 1
Date/Instructor 2/7/23 H. Gines, RN
Initials
Faculty Comments Sweet attitude and teachable. Very kind and gentle toward patient. Gained experience with new
equipment: NG to LIWS, Ileostomy with drainage bag, IV fluids, Midline, Bladder scanner!
Unprepared for clinical. Clinical binder missing unit specific sheet and vitamin supplement
MAC. Binder unorganized and messy. Please correct this issue before clinical next week.
Increase details and accuracy with narrative note (NN) charting and rounding form (RF).
Evaluated VS accurately. Next week focus on organization and being prepared.
Student Reflection I did not organize my binder and I was missing some pages. So, I will work on be organized and
practice before next clinical days
Action Plan I will buy binder separate sheets to organized my binder and practice twice a week.
Lab Remediation
Day 2
Date/Instructor 2/14/23 TS 4E
Initials
Faculty Comments Much improved with organization! Your clinical binder was well organized and you were able to
quickly locate what you needed. Good med prep and recognition of information you needed for
safe med administration. You got to give Heparin SQ today! Good job! Good assessment of
Foley, O2, IVF. Good PA with BMN! Increase speed with PA by combining multiple specific
assessments at various body parts (while assessing pulses in arms and legs, you could combine
BMN assessments while you’re there). Remember to fix your PCC SN patch on your uniform
top. T Smith BSN RN CPN
Student Reflection I need to work on the speed of physical assessment, and I need to fix my PCC SN patch before
next clinical day
Action Plan Fix the PCC SN Patch and practice with friends in nursing lab before my next clinical day work
on the speed and completion.
Lab Remediation
Day 3
Date/Instructor 2/14/23
Initials [Link], BSN, CCRN, SCRN
Faculty Comments 4E: Grace cared for a post-stroke patient today. She had very sweet bedside manners. Respectful
to the patient and all the staff on the floor. Demonstrated patient-centered care throughout the
morning. The patient truly appreciated it and left a comment form for Grace. Work on increasing
the smoothness of medication administration. Make sure you check each med carefully. Make
sure you scan meds one by one. Work on your time management. Increase your time urgency,
especially early morning. Stay focused. Keep working on your documentation. Good job overall
today.
Student Reflection I need to work on the meds scan one by one and check medication carefully.
Action Plan I will go through the medication process in nursing lab before next clinical day.
Lab Remediation
Day 4
Date/Instructor 2/28/23 H. Gines, RN
Initials
Faculty Comments SHH 4E: Thorough PA, just work to increase your speed. Please come work with an instructor in
the lab so we can help you. Continue practicing med pass for smoothness. Following correct
process though! Good MAC. Good technique giving SQ injection. Continue working on details
and accuracy when documenting the NN and RF. Showing some connections on CM. Remember
to always keep patient safety a priority especially in regards to bed level down. You are making
steady improvements. Keep it up!
Student Reflection I need to work on my physical assessment speed, and work on my accuracy about document NN
and RF
Action Plan I will go practice in nursing lab, and ask instructor to help me to count the time.
Lab Remediation
Day 5
Date/Instructor 3/14/23
Initials [Link], BSN, CCRN, SCRN
Faculty Comments SHH 4E: Grace had good time management this am. Demonstrated pt-centered care. Very
helpful in assisting a dementia patient with various tasks. Clear communication with the RN and
the instructor. Be more organized throughout the day. Pay attention to the details of your
narrative notes. Make sure you always go to the patient’s room STAT when the fall light is on.
Student Reflection I did well on time management today. I also need to work on organizing the next clinical day.
Also practice on narrative notes
Action Plan I will go look at all my narrative notes for instructor revise and recommendation to help me to
write a better narrative note next time.
Lab Remediation
Day 6
Date/Instructor 3/21/23 AR
Initials
Faculty Comments SN had a very good day. Time management was very good today! Had a pt with 11 meds; Had
VS, PA, and MAC lookup done (working around AM therapy schedule) and ready to give meds
by 08:30. Pt had a PEG tube, and worked with contact isolation for the first time. SN was able to
have all paperwork completed early and able to help fellow SN with AM care. Made herself
available to help without prompting.
Student Reflection
Action Plan
Lab Remediation
Day 7
Date/Instructor
Initials
Faculty Comments
Student Reflection
Action Plan
Lab Remediation
Day 8
Date/Instructor
Initials
Faculty Comments
Student Reflection
Action Plan
Lab Remediation
Day 9
Date/Instructor 1/31
Initials [Link], BSN, CCRN, SCRN
Faculty Comments 4E: Orientation Day. Controlled nervousness throughout the morning. Grace is very polite and
kind to the patient. She identified the abnormal vital signs. Make sure you re-check the vitals
when you have abnormal VS. Make sure you practice checking the VS with Dynamap in 5
minutes. Work on time management and being more organized.
Student Reflection I miss a few things in physical assessments. I need to be working on do not being nervous and
more smoothly complete physical assessments without missing anything.
Action Plan I will go find a partner and practice at least three times before the next clinical day.
Lab Remediation