4/4/25, 1:11 PM Faculty Site Visit Evaluation of Learner Role Transition to Nurse Practitioner
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Respondent
55 Mark Larsen 41:57
Time to complete
1. Learner's Name
Kyle Roth
2. Total completed clinical hours by the learner in the program at time of facility site visit
Up to 200 clinical hours
201-400 clinical hours
401-600 clinical hours
601-810 clinical hours
3. Name of Faculty
Mark Larsen
4. Name of Preceptor and Clinical Site
Dr. Jeffers- Franklin County Internal Medicine
5. Describe patient encounters (age, gender, CC/diagnoses)
2-26-25 81yo Male- Chronic cough; 2-20-25 35yo Male- Return to Work/syncope; 2-18-25 18yo Female- anxiety-Insomnia
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4/4/25, 1:11 PM Faculty Site Visit Evaluation of Learner Role Transition to Nurse Practitioner
6. When completing the following statements, select one level per statement. Use the following descriptions to determine the level
of competency of the learner. For statements not able to be leveled, you will select Met, Not Met or N/A.
IMPORTANT- you must save the completed form as a PDF before submitting. Email the PDF
form through Canvas to the learner and lead faculty of the practicum course. The learner
will be responsible for reviewing and uploading the PDF form into Canvas under the Faculty
Site Visit Evaluation assignment.
Level 1: Novice Learner
Observation or assists the provider during patient encounters or procedures. Progresses to partial independence during
patient encounters.
The focus is on the completion of acute visits and well exams, although all types of patient care may be encountered,
assessed, and managed by the learner. Activities may include data gathering, conducting routine H & Ps, and health
promotion/risk reduction activities.
Level 2: Advanced Beginner Learner
Gains independence in conducting a patient encounter with input from the preceptor.
The focus is on the enhancement of acute visits and well exams along with beginning to manage chronic disease. The
learner will start incorporating referrals to other healthcare professionals in their plan of care and understand the
implications of this dimension in terms of coordinating primary care. Emphasis on interprofessional collaboration,
working together to provide patient-centered care.
Level 3: Competent Learner
Building on previous knowledge, clinical skills, and critical thinking.
The focus is the management and follow up of patients with chronic diseases in addition to previously learned acute
content. Learners will continue to refine all aspects of the clinical encounter.
Level 4: Proficient Learner
Transitioning into the advanced practice role.
The focus is the addition of complex disease processes, care coordination, and previously learned content. The learner
sees a patient without preceptor consultation during the patient visit. However, the learner must succinctly present the
patient's case to the preceptor prior to the patient leaving.
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4/4/25, 1:11 PM Faculty Site Visit Evaluation of Learner Role Transition to Nurse Practitioner
7. Complete the following:
Level 1 Level 2 Level 3 Level 4 NA
Obtains a
comprehensive
and problem-
focused HPI
from the
patient and/or
family utilizing
evidence-based
screening tools
when
appropriate.
Obtains a
comprehensive
and problem-
focused ROS
from the
patient and/or
family.
Obtains a
comprehensive
and problem-
focused PMH,
FH, SH from the
patient and/or
family utilizing
evidence-based
screening tools
when
appropriate.
Performs a
comprehensive
and problem-
focused
physical
examination
using correct
assessment
techniques and
equipment.
Collects,
maintains, and
documents the
patient’s health
care
information in a
confidential and
timely manner.
Differentiates
between
normal,
variations of
normal, and
abnormal
findings
Demonstrates
critical thinking
in diagnostic
ordering and
interpretation.
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Level 1 Level 2 Level 3 Level 4 NA
Organizes
clinical
information and
integrates
advanced
scientific
knowledge to
arrive at
appropriate
differentials and
final diagnosis.
Formulates and
prioritizes a
plan of care
based on
scientific
rationale,
evidence-based
standards of
care, and
clinical practice
guidelines.
Translates
advanced
practice
knowledge to
improve patient
outcomes
Integrates and
counsels the
patient on the
use of non-
pharmacologic
therapies based
on patient-
centered
characteristics.
Develops and
implements a
patient-
centered plan
of care to
include health
promotion,
disease
prevention and
management,
as well as
palliative and
end-of-life care
as appropriate.
Provides
anticipatory
guidance and
counseling for
patients and/or
families
Verbally
communicates
the patient’s
health status
accurately to
the preceptor in
a timely and
succinct
manner.
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Level 1 Level 2 Level 3 Level 4 NA
Evaluate the
results of
previous or
current
interventions
and revise the
plan
appropriately.
Assesses the
patient’s and/or
family’s needs
and readiness
for
learning based
on personal
characteristics.
Provides
appropriate
teaching,
coaching,
educational
materials,
guidance, and
counseling
regarding the
management of
health/illness
conditions and
self-
management
when
appropriate.
Communicates
and engages in
shared
decision-
making with the
patient, family
and/or faculty
using effective
and appropriate
techniques,
including
motivational
interviewing,
with
considerations
of determinates
of health.
Correctly
describes
and/or
performs
primary care
procedures
within the
scope of
practice.
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8. Complete the following:
Met Not Met N/A
Uses available
community
resources in
designing
patient-
centered plans
of care
Consult and
refer
appropriately
with the
preceptor and
other health
care team
members.
Demonstrates
behaviors of
self-efficacy,
ethics, and
advocacy in
patient
encounters.
Engages in self-
evaluation
concerning
practice.
Uses strategies
to reduce
common errors
and/or risks.
Considers
barriers to
access, cost,
efficacy, and
quality when
making health
care decisions.
Fosters and
evaluates team
dynamics to
strengthen
desired
outcomes
Utilizes
informatics
appropriately.
Safely
prescribes
appropriate
patient-
centered
pharmacologica
l treatment
modalities.
Demonstrates
empathy and
compassion in
communication
with patients,
family, staff,
and faculty
using effective
and appropriate
techniques
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Met Not Met N/A
Facilitates
difficult
conversations
and disclosure
of sensitive
information
Demonstrates
safe,
professional
behavior
9. Discuss the learner's individual clinical objectives. Does the learner believe they have achieved their clinical objectives? If not,
what is their plan to accomplish their objectives? Remind learners to document if they were able to achieve their objectives in
the clinical reflection paper at the end of the semester. Comment below.
Objective of seeing more complex patients. Has met objective.
10. Describe the strengths of learner
Understands complex patient scenarios and treatments
11. Describe the opportunities for improvement for the learner
Think of all options for patient treatments and evaluation, i.e. chest x-ray for chronic cough
12. Evaluate the qualities of the preceptor and the clinical site
While there is a large patient population, with lots of opportunity for Cannot fully evaluate the site, as the preceptor would not allow an on site visit
13. The learner's level of skill is appropriate for the clinical hours taken.
Yes
No
14. Percentage of expected clinical level and above transcribed from rubric.
100
15. The learner has met the expectations of the clinical site visit
yes
no
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16. Additional Comments
17. Important - you must save this completed form as a PDF before submitting it, Have you done this?
yes
no
18. Type of site visit:
In Person Site Visit
Virtual Site Visit
Alternate Site Visit
19. Comments and explanation of type of site visit.
Preceptor would not allow an in person site visit. Discussed patients and care with learner via alternate site visit guidelines.
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