Clinical 20Evaluation 20Tool 20 Faculty by 2rwZZG


									                                     MICHIGAN STATE UNIVERSITY: COLLEGE OF NURSING

                               NUR 834 COMPREHENSIVE CLINICAL EVALUATION TOOL (Faculty Version)

Evaluation is based on the standards of gerontological nursing care, course objectives and minimum competency expectations for advanced
practice nursing students. During NUR 834, it is expected that the APN student is able to care for patients with complex health problems in an
organized and competent manner. The measurement criteria for each category will be based on a variety of information including:
class/email/web participation and decorum, faculty-student interactions, preceptor input, documentation, evidence based literature, expectations
of advanced practice nursing students and faculty expertise.

Each category is designated separately and the minimum expectation for meeting that category objective is listed. It is expected that category
specifications will guide student practice and be considered the minimum standard for clinical competency. Each category must be passed in
order to pass the course.

The following point scale will be utilized for objective scoring purposes:
              0 = not met (student either did not complete or did not reach the minimal foundational expectation of functioning)
              1 = minimal (below expected APN student level)
              2 = satisfactory (performing skills at the expected student level)
              3 = exceptional (performing skills at a level that exceeds expectations for an APN student)
            N/A = not applicable for specific clinical site (rationale for why N/A is valid must be documented except where * appears)

Student Name: _________________________________________________________________                          Date: _________________________

Faculty Evaluator: ______________________________________________________________

Final Score: _______________________________


Page 1 of 10
                                        CATEGORY / EXPECTATION                                                        N/A   0   1   2   3

I. ASSESSMENT: priority of data collection is determined by the patient’s immediate condition, needs and/or
                     values; evidence of abnormal function or adverse health risks are obtained; patient strengths;
                     information is appropriate, comprehensive & individualized considering patient condition,
                     ability, functional status & living arrangements. (minimum = 22)
Demonstrates logical, thoughtful critical thinking & decision making skills related to assessment
Obtains a comprehensive and/or problem focused health history from the patient (or appropriate others)
Functional status information obtained (ADLs, IADLs)
Physical exam is performed in a logical, systematic fashion (comprehensive or problem focused)
Psychological & cognitive status data obtained
Develops an acceptable and logical approach to a comprehensive geriatric assessment
Culture & ethnicity information elicited that may affect health status & learning experiences
Gathers & reviews information and addresses patient issues around:
   Spirituality and/or religion
   Safety issues
   Support systems & resources
   Patient’s response to the aging process
   Life style & interpersonal relationships
   Health beliefs & practices
   Perception of & satisfaction with health status
   Strengths & competencies for health promotion
   Communication skills
   Social and economic status
History of health patterns & illness (es) addressed
Medication & self-medication practices (Rx, OTC, herbals & botanicals) evaluated for safety & potential
interactions with every patient, every visit
Coping skills (type, effectiveness, adaptive or maladaptive) identified
Advance directives discussed and/or advance care planning initiated
Gains an understanding into the priorities and goals (values) of every individual patient
                                                                                        TOTAL POINTS (x 1)

Page 2 of 10
                                       CATEGORY / EXPECTATION                                                    N/A   0   1   2   3

II. DIAGNOSIS: derived from & supported by documented assessment data (subjective & objective); based on
               accepted classification systems such as NANDA, ICD, agency requirements; written in an
               accepted format & structure; individualized; clear & concise (minimum = 30)

Demonstrates logical, thoughtful critical thinking & decision making skills related to diagnosis
Analyzes & interprets history, presenting symptoms & physical findings to formulate differential diagnoses
Medical diagnoses identified (actual)
Nursing diagnoses identified (actual & potential)
Analyzes & interprets history, presenting symptoms, physical findings & diagnostic information to develop
differential diagnosis
Differential diagnoses discussed with preceptor
Potential problems or health problems identified
Patient strengths recognized & documented
Health promotion/wellness issues identified & discussed with the patient
Diagnoses & risk factors validated with patient, significant others & other health care providers as
appropriate & possible
Able to identify patient self-care limitations or impaired functioning
Able to identify patient issues such as maintaining optimal health & well-being, preventing illness, restoring
health &/or allowing a peaceful death
Emotional, social, economic, environmental & spiritual problems identified
Able to identify patient & caregiver education & health care knowledge needs
Notes alterations in patient thinking, perceiving, communicating & decision making
Able to diagnose side effects of pharmacological intervention or other treatment regimens
ALL diagnoses are documented in a manner that facilitates expected outcomes

                                                                                     TOTAL POINTS (x 1)

Page 3 of 10
                                         CATEGORY / EXPECTATION                                                N/A   0   1   2   3

III. OUTCOMES: a measurable individual, family, or community state, behavior or perception that is measured
               along a continuum & is responsive to interventions; individualized; developed with mutuality;
               prioritized accurately (minimum = 18)

Demonstrates logical, thoughtful critical thinking & decision making skills related to patient outcomes

Derived from diagnoses

Documented as measurable goals

Mutually formulated with the patient, their significant other & interdisciplinary team members when
appropriate & possible

Realistic in relation to the patient’s present & potential capabilities

Attainable in relation to resources available to patient & their care setting

Identified with consideration of associated benefits & costs

Include a time estimate for attainment

Provide direction for continuity of long term care

Uses an evidence based approach to patient management that critically evaluates & applies research pertinent
to patient care & outcomes

                                                                                    TOTAL POINTS (x 1)

Page 4 of 10
                                       CATEGORY / EXPECTATION                                              N/A   0   1   2   3

IV. PLANNING: individualized to a patient’s health status or needs; comprehensive; holistic; realistic
             (minimum = 36)

Demonstrates logical, thoughtful critical thinking & decision making skills related to planning
Formulates an action plan based on scientific rationale, evidence based standards & practice guidelines
Identifies priorities of care in relation to expected outcomes (EOs)
Identifies effective interventions to achieve EOs
Specifies interventions that reflect current Gerontological nursing practice & research
Includes educational components for health maintenance, self-care, medications & treatment
Includes environmental modifications when appropriate                                                       *
Indicates responsibilities of specific health team members, patient or caregivers, when appropriate         *
Identifies sequence of actions to achieve EOs
Verbal &/or written instructions given to patients &/or caregivers when appropriate & possible
Provides for appropriate referral & case management to ensure continuity of care
Provides for quality of life as perceived by the patient &, when appropriate, a peaceful death
Addresses specific needs of the patient in regards to:
   Therapeutic regimen
   Preventive regimen
   Restorative regimen
   Rehabilitative regimen
Settings for services are appropriate to the patient’s condition
Proposes alternatives for continuity of care for long term needs
Identifies resources required to accomplish care plan & EOs
Includes a discharge plan when appropriate                                                                  *
Aware of available resources in the community & includes as appropriate in the plan of care
Developed in collaboration with the patient, significant others & interdisciplinary team members, when
Documented so other team members can access, review & modify

                                                                                      TOTAL POINTS (x 1)

Page 5 of 10
                                       CATEGORY / EXPECTATION                                                    N/A   0   1   2   3

V. IMPLEMENTATION / INTERVENTIONS: utilizes advanced independent nursing interventions when
                    managing individuals with stable chronic health status; include nursing focus with
                    NIC guidelines; are appropriate& achievable (minimum = 48)

Demonstrates logical, thoughtful critical thinking & decision making skills related to implementation &
Selected on basis of needs, desires & resources of patient & accepted nursing practice
Appropriate to APN level of education, certification & practice
Interventions implemented within the established care plan & facilitate optimal functioning, self-care, health
promotion, disease prevention, health teaching & counseling
Include specific treatments
Include medications & precise, individualized instructions and counseling including drug regimen, side
effects, possible interactions, adverse reactions or monitoring of effects
Prescribes medication based on efficacy, safety & cost as legally authorized
Are safe, ethical & indicate awareness of cultural differences
Include palliative care, when appropriate                                                                         *
Include caregiver education & training, when appropriate & possible                                               *
Include case management
Implemented in a safe, ethical, culturally competent & appropriate manner
Applies principles of self-efficacy & empowerment in promoting behavior change
                                                                                      TOTAL POINTS (x 2)
VI. EVALUATION: systematic & ongoing; comprehensive; revises plan & consults or refers as necessary
                       (minimum = 20)

Demonstrates logical, thoughtful critical thinking & decision making skills related to evaluation
Patient, significant others & health team members are involved in evaluation process, as appropriate &
Patient’s response at follow-up is documented
Effectiveness of interventions is evaluated in relation to EOs
Diagnoses, EOs & plan of care is revised through ongoing assessment & follow-up
Revisions to plan of care are discussed with patient, significant other or caregiver & documented

Page 6 of 10
                                      CATEGORY / EXPECTATION                                                     N/A   0   1   2   3

                                                                                         TOTAL POINTS (x 2 )
VII. DOCUMENTATION: (minimum = 44)
Demonstrates logical, thoughtful critical thinking & decision making skills related to documentation              *
Utilizes appropriate terminology, abbreviations & spelling
Uses SOAP format accurately                                                                                       *
HPI’s are organized, complete & accurate                                                                          *
Hx & PE’s are organized, complete & accurate
Coding of visit & charting content are consistent & accurate                                                      *
Records collaborative & consultative activities                                                                   *
Provides encounter data & clinical logs to faculty in the required timely manner                                  *
                                                                                      TOTAL POINTS (x 3)
Demonstrates advanced knowledge of pathophysiology of chronic disease conditions by ability to articulate         *
thoughts & information accurately
Demonstrates advanced knowledge of pharmacology by ability to provide scientific rationale & judgment for         *
medications chosen to treat patient conditions
Assesses, diagnoses, monitors, coordinates & manages the health/illness status of patients over time              *
Applies appropriate theories to guide practice                                                                    *
Evaluates the impact of life transitions on health/illness status of patients & recognizes impact of health &     *
illness on individuals & their families
Maintains confidentiality while communicating data, plans & results in a manner that preserves the dignity &      *
privacy of the patient as well as providing a legal written record of care
Assumes primary responsibility for developing diagnosis & determining plan of care for patients seen              *
Demonstrates increasing independence in clinical decision making                                                  *
Creates a relationship that acknowledges the patient strengths & assists the patient in addressing his/her own    *
Initiates appropriate & timely consultation &/or referral when the problem exceeds the nurse practitioner         *
student’s scope of practice
Provides care for individuals, families & communities within an integrated health care system                     *
Functions in a variety of role dimensions: health care provider, case manager, consultant, educator, coach,       *
advocate, researcher & leader
Demonstrates increasing improvement in advanced practice role                                                     *

Page 7 of 10
                                       CATEGORY / EXPECTATION                                                      N/A   0   1   2   3

                                                                               TOTAL POINTS (x 2)
IX. PROFESSIONALISM: (minimum = 40)

Notifies preceptor &/or clinic staff about any unforeseen absences or tardiness                                     *
On time                                                                                                             *
Dressed appropriately for clinic setting                                                                            *
Provides appropriate written materials to preceptor, clinic staff & faculty                                         *
Demonstrates respect for the inherent dignity of every human being regardless of age, gender, religion, sexual      *
orientation, socioeconomic status, ethnicity or cultural group
Develops & maintains a positive working relationship with preceptor & other health team staff                       *
Develops & maintains a positive working relationship with the faculty                                               *
Develops therapeutic working relationships with patients & their families or caregivers                             *
Able to accept constructive feedback & comments from faculty/peers/preceptors/patients/others                       *
Monitors & reflects on own emotional responses to interactions with patients & uses data to further                 *
therapeutic interactions
Interprets own professional strengths, role & ability related to peers, patients & colleagues                       *
Engages in self evaluation concerning health care practice & strives to attain the highest standards of practice    *
Appropriately seeks consultation & collaboration                                                                    *
Communicates effectively & therapeutically with patients & others                                                   *
Displays “eager motivation” to learn                                                                                *
Maintains a positive attitude                                                                                       *
Presents & articulates patient information in an organized, concise, systematic manner                              *
Evaluates own progress honestly & accurately in developing advanced practice role                                   *
Actively participates in clinical conferences offering evidence-based, logical, thoughtful comments                 *
Reviews & evaluates peers constructively                                                                            *
Paperwork is neat & turned in on time                                                                               *
Understands & practices within ethical principles & guidelines of health care practice                              *

                                                                                     TOTAL POINTS (x 1)

Page 8 of 10
                                      CATEGORY / EXPECTATION                          N/A   0   1   2   3

                                   NUR 834 CLINICAL EVALUATION SCORING FORM

Student Name: _______________________________________________________       Date: _____________________

Evaluator: ___________________________________________________________

                               CATEGORY                   N/A   0   1   2    3   WEIGHT         TOTAL

ASSESSMENT (22)                                                                     X1

DIAGNOSIS (30)                                                                      X1

OUTCOMES (18)                                                                       X1

PLANNING (36)                                                                       X1

IMPLEMENTATION / INTERVENTIONS (48)                                                 X2

EVALUATION (20)                                                                     X2

DOCUMENTATION (44)                                                                  X3

ADVANCED PRACTICE ROLE (48)                                                         X2

PROFESSIONALISM (40)                                                                X1

Page 9 of 10

Page 10 of 10

To top