Northeastern University

Physical Therapy Student Data Form I. Student’s Personal Data (Please Print) Name ______________________________________________ Clinical Experience (circle) 1 2 3 Preferred Mailing Address_____________________________________________________________City____________________State______________Zip_____________ Phone_____________________________________________Alternative Phone _____________________________________E-Mail__________________ Liability InsuranceCarrier: University of North Florida Medical Insurance:______________________________Policy #___________ In Case of Emergency Contact_______________________________________________________Relationship___________________________________ Address________________________________________________________________________City________________ State_____________ Zip_______ Phone_______________________________________ Previous Clinical Experiences Dates Facility Position Length of Experience Type of Experience (e.g. acute, outpatient, etc.) Housing Information I would: ______ like to take advantage of the housing you offer ______ like to review any housing information you may have available I have housing available at _________________________________ I have a car _____ I will rely on public transportation _____ Adapted from the Student Data Form of the The New England Consortium of Academic Coordinators, Inc. II. LEARNING STYLE PROFILE A. Please describe how you learn most easily. Include teaching strategies that you find most effective for you. B. Please comment on the amount and type of feedback you prefer while learning in a clinical setting. III. STUDENT SELF-ASSESSMENT Overview: The 24 items of the Clinical Performance Instrument (CPI) are grouped into categories (Affective Dimensions/Professional Behavior, Documentation, Elements of Patient/Client Management, Prevention/Wellness, Other Professional Roles and Resources). Performance Items are described in the left hand column. Directions: 1. In the second column, using the following key, indicate your level of exposure to each of the items. 0 = no exposure 1 = classroom only 2 = classroom and lab 3 = clinic only 4 = clinic, classroom and lab 2. In the third column, using the performance dimensions described below, indicate your level of performance for each of the items listed by placing a vertical mark on the visual analog scale (VAS) provided. The left hand anchor represents novice clinical performance, and the right hand anchor indicates entry-level performance as described below and in the CPI. 3. In the last column, using the performance dimensions described below (quality, supervision required, consistency, complexity, and efficiency) as a framework, provide a general statement of your performance for the category of items listed. NOTE: Steps 1 and 2 provide a visual representation of your perceived level of performance. Step 3 provides a general overview of your exposure and competence in narrative form, and complements the information previously given to insure a well-rounded picture of your capabilities. 2 Definitions: Novice Clinical Performance = A physical therapist student who provides quality care only with uncomplicated patients and a high degree of supervision. Without close supervision, the student’s performance and clinical decision making are inconsistent and require constant monitoring and feedback. This is typically a student who is inexperienced in clinical practice or who performs as though he or she has had limited or no opportunity to apply academic knowledge or clinical skills. Entry-level Performance = A physical therapist clinician performing at entry-level utilizes critical thinking to make independent decisions concerning patient needs and provides quality care with simple or complex patients in a variety of clinical environments. The physical therapist clinician at the professional level needs no guidance or supervision except when addressing new or complex problems. Performance Dimensions: Quality = the degree of skill or competence demonstrated (eg, limited skill, high skill), the relative effectiveness of the performance (eg, ineffective, highly effective), and the extent to which outcomes meet the desired goals. A continuum of quality might range from demonstration of limited skill and effectiveness to a highly skilled and highly effective performance. Supervision/guidance required = level and extent of assistance required by the student to achieve clinical performance at entry-level. As a student progresses through clinical education experiences, the degree of monitoring needed is expected to progress from full-time monitoring/direct supervision or cuing for assistance to initiated, to independent performance with consultation. The degree of supervision and guidance may vary with the complexity of the patient or the environment. Consistency = the frequency of occurrences of desired behaviors related to the performance criterion (eg, infrequently, occasionally, routinely). As the student progresses through clinical education experiences, consistency of quality performance is expected to progress from infrequently to routinely. Complexity of tasks/environment = Multiple requirements of the patient or environment (eg, simple, complex). The complexity of the environment can be altered by controlling the number and types of elements to be considered in the performance, including patients, equipment, issues, etc. As a student progress through clinical education experiences, the complexity of tasks/environment should increase, with fewer elements controlled by the CI. Efficiency = the ability to perform in a cost-effective and timely manner (eg, inefficient/slow, efficient/timely). As a student progresses through clinical education experiences, efficiency should progress from a high expenditure of time and effort to economical and timely. Elements of this Form are adapted with permission of the American Physical Therapy Association from Physical Therapy Clinical Performance Instrument, Alexandria, Virginia, American Physical Therapy Association, 1998 3 Please use the following key to choose responses: 0 = no exposure 1 = class only 2 = class and lab 3 = clinic only 4 = clinic, class and lab See page 3 for novice and entry level and performance definitions See page 3 for performance dimensions descriptors to include in this comment Affective Dimension/Professional Behaviors CPI Performance Item Exposure (circle) Competence 1. Practices in a safe manner that minimizes risk to include to patients self, and others (observes health and safety regulations; maintains safe working environment; 01234 recognizes physiological and psychological changes in patients and adjusts treatment novice entry accordingly; demonstrates awareness of contraindications and precautions of level treatment; requests assistance when necessary; uses acceptable techniques for safe handling of patients; protects welfare of self, patient, and others in emergency situations). 2. Presents self in a professional manner (Accepts responsibility for own actions; is punctual and dependable; completes scheduled assignments in a timely manner; 01234 wears attire consistent with expectations of the practice setting; demonstrates novice entry initiative; abides by the policies and procedures of the practice setting; adapts to level change). 3. Demonstrates professional behavior during interactions with others (Maintains productive working relationships with patients, families, CI and others; treats others 01234 with positive regard, dignity, respect, and compassion; maintains objectivity; novice entry demonstrates behaviors that contribute to a positive work environment; accepts level criticism without defensiveness; manages conflict in constructive ways; makes choices after considering the consequences to self and others; assumes responsibility for choices made in situations presenting legal or ethical dilemmas; maintains patient privacy and modesty (eg, draping, confidentiality). 4. Adheres to ethical practice standards (Abides by relevant ethical codes and standards of practice guidelines; adheres to institutional policy and procedures; 01234 identifies situations in which ethical questions are present; reports violations of novice entry ethical practice). level 5. Adheres to legal practice standards (Abides by pertinent state province) and federal laws and regulations, including those applying to state licensure laws; 01234 identifies situations in which legal questions are present; reports violations of laws novice entry governing practice of physical therapy). level Comments 4 CPI Performance Item 6. Communicates in ways that are congruent with situational needs. (Communicates, verbally and nonverbally, in a professional and timely manner; initiates communication in difficult situations; selects the most appropriate person(s) with whom to communicate; communicates respect for the roles and contributions of all participants in patient care; listens actively and attentively to understand what is being communicated by others; demonstrates professionally and technically correct verbal communication; communicates using nonverbal messages that are consistent with intended message; interprets and responds to the nonverbal communication of others; evaluates effectiveness of his/her own communication and modifies communication accordingly). 8. Adapts delivery of physical therapy care to reflect respect for and sensitivity to individual differences. (Exhibits sensitivity to differences in race, creed, color, gender, age, national or ethnic origin, sexual orientation, and disability or health status in communicating with others, developing plans of care and implementing plans of care). 22. Demonstrates that a physical therapist has professional/social responsibilities beyond those defined by work expectations and job description. (Demonstrates a willingness to alter schedule to accommodate patient needs and facility requirements; participates in special events organized by the practice setting related to patients and the delivery of care; participates in professional organizations and service groups; promotes the profession of physical therapy). 23. Implements a self-directed plan for professional development and lifelong learning. (Demonstrates an awareness of strengths and limitations; seeks guidance as necessary to address limitations; modifies behavior based on self-evaluation and constructive feedback; establishes realistic goals in a plan for professional development; participates in learning experiences within the practice setting; participates in opportunities for professional growth; discusses progress of professional growth; seeks opportunities to learn; accepts responsibility for continuous professional learning; demonstrates knowledge of current professional issues and practice; periodically assesses own professional development). Exposure 01234 novice Competence Comments entry level 01234 novice entry level 01234 novice entry level 01234 novice entry level 5 Documentation CPI Performance Item 7. Produces documentation to support the delivery of physical therapy services. (Selects relevant information to document the delivery of physical therapy patient care; documents all aspects of physical therapy care, including screening, examination, evaluation, plan of care, treatment, response to treatment, discharge planning, family conferences, and communication with others involved in delivery of patient care; produces documentation that follows guidelines and format required by the practice setting; documents patient care consistent with guidelines and requirements of regulatory agencies and third-party payers; produces documentation that is accurate, concise, timely, and legible; demonstrates professionally and technically correct written communication skills. Exposure 01234 novice entry level Competence Comments Elements of Patient/Client Management CPI Performance Item 10. Screens patients using procedures to determine the effectiveness of and need for physical therapy services. (Identifies critical signs and symptoms that signal appropriateness for physical therapy examination; selects appropriate screening procedures; conducts screening; interprets screening findings; based on screening, determines appropriateness for physical therapy or referral to other providers; performs physical therapy screening in a technically competent manner). 11. Performs a physical therapy patient examination. (Selects reliable and valid physical therapy examination methods relevant to the chief compliant, results of screening, and history of the patient; obtains accurate information by performing the selected examination methods; adjusts examination according to patient response; performs examination minimizing risk to patient, self and others involved in the delivery of the patient care; performs physical therapy examination procedures in a technically correct manner). Note: See appendix for list of tests and measures and items to consider during history (from the CPI and the Guide to Clinical Practice). Exposure 01234 novice entry level Competence Comments 01234 novice entry level 12. Evaluates clinical findings to determine physical therapy diagnoses and 6 outcomes of care. (Synthesizes examination data to complete the physical therapy evaluation; interprets clinical findings to establish a diagnosis within the practitioner’s knowledge base; identifies competing diagnoses which must be ruled out to establish a diagnosis; explains the influence of pathological, pathophysiological and pharmacological processes on the patient’ s movement system; identifies other medical, social, or psychological problems influencing Physical Therapy and not identified through diagnosis of patient’s problem; uses clinical findings base; performs regular re-examinations of patient status; performs regular evaluations of the effectiveness of patient treatment; evaluates changes in patient status). NOTE: See appendix for diagnoses from the Guide to Clinical Practice 13. Designs a physical therapy plan of care that integrates goals, treatment, outcomes and discharge plan. (Establishes goals and desired functional outcomes that specify expected time duration; establishes a physical therapy plan of care in collaboration with the patient, family, caregiver, and others involved in the delivery of health care services; establishes a plan of care consistent with the examination and evaluation; establish a plan of care minimizing the risk to the patient and those involved with the delivery of the patient's care; establishes a plan of care designed to produce the maximum patient outcome(s) utilizing available resources; adjusts the plan of care in response to changes in patient status; selects intervention strategies to achieve the desired outcomes; establishes a plan for patient discharge in a timely manner). 14. Performs physical therapy interventions in a competent manner. (Performs effective, efficient, fluid, and coordinated movement in providing technically competent interventions for patients’ performs interventions consistent with the plan of care; provides intervention in a manner minimizing risk to self, to the patient, and to others involved in the delivery of the patient’s care; uses intervention time efficiently and effectively; adapts intervention to meet the individual needs and responses of the patient). NOTE: See appendix for list of interventions (from the CPI and Guide to Clinical Practice). 9. Applies the principles of logic and the scientific method to the practice of physical therapy. (Presents cogent and concise arguments or rationale for clinical decisions; makes clinical decisions within the context of ethical practice and informed consent; utilizes information from multiple data sources to make clinical decisions; seeks disconfirming evidence in the process of making clinical decisions; critically evaluates published research articles relevant to physical therapy and applies to clinical practice; participates in clinical research; describes sources of error in the collection of clinical data; demonstrates an ability to make clinical decisions in ambiguous situations; distinguishes practices based on traditional beliefs from practices that are scientifically based; uses appropriate outcome measures in the delivery and assessment of ongoing patient care). 01234 novice entry level 01234 novice entry level 01234 novice entry level 01234 novice entry level Prevention/Wellness 7 CPI Performance Item Exposure 24. Addresses primary and secondary prevention, wellness, and health promotion needs of individuals, groups and communities. (Educates patients 01234 or other individuals, groups, or communities on health promotion, prevention, and wellness by providing information on impairment, disease, disability, and health risk related to age, gender, culture and lifestyle; incorporates the concept of self-responsibility in wellness and health promotion; proposes procedures for monitoring effects of health promotion, prevention or wellness programs; describes potential health problems addressed by physical therapy in individuals, groups, and communities; performs screening programs appropriate to physical therapy). Competence Comments novice entry level Other Professional Roles CPI Performance Item 15. Educates others (patients, family, caregivers, staff, students, other health care providers) using relevant and effective teaching methods. (Identifies and establishes priorities for educational needs in collaboration with the learner; designs educational activities to address identified needs; conducts educational activities using a variety of instructional strategies as needed; evaluates effectiveness of educational activities; modifies educational activities considering learner’s needs, characteristics, and capabilities.) 16. Participates in activities addressing quality of service delivery. (Seeks information regarding quality of care rendered by self and others under their supervision; provides recommendations for developing or modifying guidelines based on outcome measures, effectiveness studies, and clinical observations; follow established guidelines for the delivery of physical therapy services [eg, critical/clinical pathways, protocols] ). 17. Provides consultation to individuals, businesses, schools, government agencies or other organizations. (Determines need for consultation services; recommends consultation services; uses knowledge and expertise to help others solve physical therapy-related problems; provides consultation services such as ergonomic evaluations, school system assessments, and corporate environmental assessments). 18. Addresses patient needs for services other than physical therapy as needed. (Determines needs of and available resources for patients; recommends referrals based on expertise and effectiveness of providers; advocates for appropriate patient services & resources; assists patient in accessing resources; coordinates services of other care providers). Exposure 01234 novice entry level Competence Comments 01234 novice entry level 01234 novice entry level 01234 novice entry level 8 CPI Performance Item 19. Manages resources (eg, time, space, equipment) to achieve goals of the practice setting. (Sets priorities for the use of resources to maximize outcomes; functions within the organizational structure of the practice setting; uses time effectively; coordinates physical therapy with other services to facilitate efficient and effective patient care; schedules patients, equipment and space). 20. Incorporates an understanding of economic factors in the delivery of physical therapy services. (Adapts physical therapy services to the economic factors of the health care environment; submits accurate patient charges on time; acts in fiscally responsible manner; provides recommendations for equipment and supply needs; adheres to reimbursement guidelines established by payers; negotiates with reimbursement entities for changes in individual patient services). 21. Uses support personnel according to legal standards and ethical guidelines. (Determines physical therapy-related tasks that can be legally and ethically delegated; delegates physical therapy-related tasks to facilitate effective and efficient patient care; informs the patient of the decision to delegate the physical therapy-related care and the rationale for delegating; delegates physical therapy-related tasks to appropriate support personnel; demonstrates respect for the contributions of support personnel; monitors the care delivered by support personnel; provides regular feedback to support personnel). Exposure 01234 novice Competence Comments entry level 01234 novice entry level 01234 novice entry level 9 University of North Florida Student _________________________________________________________________________________________________________________________________ Clinical Experience: 1 2 3 Dates of Experience:______________________________ Assigned Clinical Education Site:________________________________ Type of Experience:__________________________________________ (eg, ortho, acute, outpatient, unknown, etc.) Summary: Based on completion of self-assessment Areas of Strength Areas to Strengthen By the end of this clinical experience, I hope to be able to: 1. 2. 3. 4. 5. Student signature:_____________________________________________________________________Date completed:________________________________ 10