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SCHOOL OF MIDWIFERY

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					                           NB: Sign off Mentors
                           Please note addition of Mentor signature sheets on pages 5/6



BSc (Hons) Midwifery 3 year Programme
Practice Document – YEAR 2 (September 2009 cohort)

Student Name: ……………………………………………………………..
Student Number: …………………………………………………………..
Cohort: ……………………………………………………………………….


Practice Associate Lecturer in Midwifery (PALM): …………………………………
Visiting Lecturer: …………………………………………………………………………
                                                                                                                Student Number: ………………………………………




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                                                                                                                Student Number: ………………………………………




                                       GUIDELINES FOR STUDENTS AND SIGN OFF MENTORS


Please note amendments/additions made September 2010 to some pages within this document:-


STUDENTS AND SIGN OFF MENTORS

1         All ‘PRELIMINARY INTERVIEW’ pages - The addition of ‘Breastfeeding Policies’ to the Orientation Check List.

2         All ‘PERSONAL TUTOR INTERVIEW – FOLLOWING COMPLETION OF EACH CLINICAL PLACEMENT’ pages - The addition of
          ‘Please remember it is expected that you meet up with your personal tutor at least twice in each year’.


SIGN OFF MENTORS

3         The addition of a ‘MENTOR SIGNATURE’ page – To be completed by all mentors who assess students, entering their name, signature,
          place of work and name of Trust.




                                                                                                                    Revised and Re-validated: May 2010

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                                                                                                                Student Number: ………………………………………




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                                                                                                                                Student Number: ………………………………………
SIGN OFF MENTOR(S) SIGNATURE SHEET


      Name of Sign Off Mentor                                           Signature                               Place of Work                 Trust Name
          (please print)




(cont’d on next page)



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                                                                                                                                Student Number: ………………………………………
SIGN OFF MENTOR(S) SIGNATURE SHEET (cont’d)


      Name of Sign off Mentor                                           Signature                               Place of Work                 Trust Name
          (please print)




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                                                                                                                Student Number: ………………………………………
THE USE OF BENNER’S MODEL TO FACILITATE ASSESSMENT OF THE NMC COMPETENCIES

The overarching philosophy of the award is to enable student midwives progressing through the programme to develop from a novice into a
competent professional. The development from novice to competent practitioner is based on part of the model of Benner (1984). This model
has five levels of proficiency: novice, advanced beginner, competent, proficient and expert.

Year One Proficiency Expectations
During year 1, students start to identify the main elements of a situation and practise midwifery skills and competencies under the guidance
and direct supervision of their sign off mentor.

Year Two Proficiency Expectations
During year 2 students build on familiar experiences and extend their application of knowledge to practice. This will enable them to identify the
important elements of a situation and provide appropriate care (in most circumstances they will require direct supervision, however there
should be some opportunity for indirect supervision).

Year Three Proficiency Expectations
In year 3 students are expected to progress from advanced beginner status to competent practitioner. There should be increased opportunity
for indirect supervision thereby acknowledging the students’ knowledge and clinical development. According to Benner (1984), attainment of
competent practitioner level, denotes an ability to prioritise care effectively in all situations. Thus competent practitioner level, equates to
newly qualified midwife status.

THE SIGN OFF MENTOR

The sign off mentor must be registered on the same part of the register as the student and working in the same field of practice as that in which
the student intends to qualify. They must have an in-depth understanding of their accountability when assessing student achievement of NMC
competencies during and at the completion of the programme (NMC 2009).

THE STUDENT – SELF ASSESSMENT

Self-assessment with active participation is essential to professional competence. The student’s own assessment of clinical achievement is seen
to be integral to their professional development. This will occur at the end of each practice placement. Additionally at the end of each year, the
student is required to sign a declaration of continuing good health and character ie no convictions or formal cautions by police (NMC 2009).

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                                                                                                                Student Number: ………………………………………

OVERVIEW OF PRACTICE PLACEMENTS DURING PROGRAMME

Practice placements should enable growth and development of the skills, attitudes and knowledge required by the student to become a
competent midwifery practitioner.

Year One
This will include nursing, antenatal, intrapartum and postnatal experience with the emphasis on basic clinical skills including those associated
with normal pregnancy.

At the completion of this year, the student should be competent to plan and implement care in situations of normality, whilst recognising
deviations which require referral. It is also important that women are observed feeding their infants in a variety of settings. It is expected that
the student will achieve all year one competencies and clinical skills that relate to the Essential Skills Clusters (NMC 2009) by the end
of the year.

Year Two
In this year normal aspects of childbirth are consolidated. Concepts of caring for women with complex issues are introduced and developed.
This will include returning to familiar placements as well as new areas such as a neonatal unit, ANC and DAU’s. It is expected that the student
will achieve all year two competencies and clinical skills by the end of year.

Year Three
During this year the emphasis is on consolidating midwifery and management skills and exploring contemporary challenges in midwifery care in
order to promote autonomous practice. There will also be an opportunity of an elective placement in this year. This year allows opportunity for a
period of novice practice concluding with the completion of NMC requirements for registration. It is expected that the student will achieve all
year one competencies and clinical skills that relate to the Essential Skills Clusters (NMC 2009) by the end of the year.




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                                                                                                                Student Number: ………………………………………



NOTES ON COMPLETION OF THE CLINICAL DOCUMENT

Each year the clinical document has a specific combination of clinical skills and competencies showing the progression through the Benner
model to meet the NMC competencies for registration. For each clinical placement, a sign off mentor is required to sign off the relevant
competencies and skills as either achieved or not achieved. To aid this, the students are required to supply supporting evidence using the
key on the following page. It is expected that the student works a minimum of two shifts per week (or equivalent) with their allocated sign off
mentor (UWE policy).

At the end of each year there will be a specified date for the hand-in of this document (see module handbook). By this date the
sign off mentor has to confirm that all the required competencies and skills have been met. This helps to inform the final year sign off
mentor who has the responsibility at completion of the programme to confirm that the student has met all the NMC competencies and is
therefore fit for practice and fit for purpose.

NB:       Competencies need to be maintained and a sign off mentor has the authority to review and reassess these at any point.


Week One
A preliminary interview should be carried out to identify learning needs and formulate an action plan between the student and sign off mentor.
Orientation to the area and a date and time for the midpoint interview should be included in this interview.

Midpoint of Placement
Throughout the placement the student should receive regular feedback regarding progress. The midpoint interview provides a formative
assessment to help identify strengths and areas that need developing. At this point the action plan should be reviewed and adjusted as
needed.

The relevant Practice Associate Lecturer in Midwifery (PALM) and the UWE Practice Support Line must be contacted if at any time
there is a cause for concern by either party. A ‘Discussion Surrounding Issues Relating to Student’s Progress’ form must then be
completed to outline the issue and develop an action plan.



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                                                                                                                Student Number: ………………………………………

End of Placement
The final interview is the summative assessment to ensure that the relevant NMC competencies have been met. In addition this will further
provide opportunity for the sign off mentor to give constructive comments on the personal qualities and attributes of the student. This should
take place in the penultimate week of the placement.

The Use of Supporting Evidence
The sign off mentor can draw on a variety of supporting evidence, which the student will provide, to help inform the assessment process. This
may also include the use of ‘an occasional use assessment document’ form completed by another midwife when the student is unable to work
with their allocated sign off mentor. The following key should be used for the documentation of this evidence. Please see sources of
evidence for definition of the terms in this key (page 77).



(RK)                Record Keeping
(O)                 Observation
(MD)                Sign off mentor Discussion
(MW)                Multi-disciplinary Working
(S)                 Simulation
(R)                 Reflection
(RES)               Research
(PG)                Policies/Guidelines
(PA)                Peer Assessment/Feedback
(UA)                User Assessment
(M)                 Meetings




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                                                                                                                Student Number: ………………………………………



STUDENT SUPPORT

It is recognised that students will need to access a variety of support mechanisms whilst in placement. These include:

         Sign off mentor

         PALM / Personal Tutor

         Supervisor of Midwives

         Student Buddy system

         Practice support line
             o Telephone: 0117 32 81152
             o Email:          hscpsl@uwe.ac.uk

         Faculty student support services eg student advisors / counselling
             o Telephone: 0117 32 88828 / 88779 / 88419

         Visiting Lecturer

This document has been developed to encourage active participation in assessment by the sign off mentor and the student to enable evaluation
of progress. The course philosophy encourages the students to take responsibility for their own learning. The students are expected to identify
their own learning needs and be proactive in seeking to fulfil these and also need to ensure during the three years, that they participate in
interprofessional collaborative working where possible.




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                                                                                                                Student Number: ………………………………………




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                                                                                                                                              Student Number: ………………………………………

OCCASIONAL USE ASSESSMENT FORM – to be used when not working with allocated sign off mentor)


Student Name: ...........................................................        Student No: …………………………….                              Cohort: .....................................................

Placement area: .......................................................... Date/s: .................................................

Allocated sign off mentor’s name: .............................................................................................................

Overview of experience obtained:




Comments - Strengths/areas for development:




Sign off mentor’s Signature: ………………………………..                                                                     Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                              Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                                   Date: …………………………………………………………..

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                                                                                                                                              Student Number: ………………………………………

OCCASIONAL USE ASSESSMENT FORM – to be used when not working with allocated sign off mentor)


Student Name: ...........................................................        Student No: …………………………….                              Cohort: .....................................................

Placement area: .......................................................... Date/s: .................................................

Allocated sign off mentor’s name: .............................................................................................................

Overview of experience obtained:




Comments - Strengths/areas for development:




Sign off mentor’s Signature: ……………………………….                                                                      Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                              Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                                   Date: …………………………………………………………..
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                                                                                                                                              Student Number: ………………………………………

OCCASIONAL USE ASSESSMENT FORM – to be used when not working with allocated sign off mentor)


Student Name: ...........................................................        Student No: …………………………….                              Cohort: .....................................................

Placement area: .......................................................... Date/s: .................................................

Allocated sign off mentor’s name: .............................................................................................................

Overview of experience obtained:




Comments - Strengths/areas for development:




Sign off mentor’s Signature: ………………………………..                                                                     Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                              Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                                   Date: …………………………………………………………..

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                                                                                                                                              Student Number: ………………………………………

OCCASIONAL USE ASSESSMENT FORM – to be used when not working with allocated sign off mentor)


Student Name: ...........................................................        Student No: …………………………….                              Cohort: .....................................................

Placement area: .......................................................... Date/s: .................................................

Allocated sign off mentor’s name: .............................................................................................................

Overview of experience obtained:




Comments - Strengths/areas for development:




Sign off mentor’s Signature: ……………………………….                                                                      Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                              Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                                   Date: …………………………………………………………..
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                                                                                                                Student Number: ………………………………………

                                                                                                                        ORIENTATION CHECK LIST
STUDENT NAME: ………………………………………………………… STUDENT NO: …………………………..                                                           (to be completed in first
                                                                                                                        week of placement)
                                                                                                                                                         Tick
PRELIMINARY INTERVIEW
                                                                                                                        Layout of clinical area
Placement: …………………………………………………………………………………….

Dates of Allocation: ………………………………………………………………………….                                                                      Policies/Guidelines

Sign off mentor(s): ……………………………………………………………………………                                                                       Bleeps/Emergency bleeps

                              …………………………………………………………………………….                                                            Telephones

                                                                                                                        Call Bell System

Student’s expectations and previous clinical (placement) experience -                                                   Emergency Equipment
(to be completed by the student prior to each placement):-
                                                                                                                        Fire Equipment, Exits
                                                                                                                        and Procedures

                                                                                                                        Procedure in case of personal
                                                                                                                        accident or injury

                                                                                                                        Procedure if student is absent
                                                                                                                        or ill

                                                                                                                        Health and Safety
                                                                                                                        Policies/Procedures

                                                                                                                        Breastfeeding Policies

                                                                                                                        Student’s
                                                                                                                        Signature: …………………………….

                                                                                                                        Sign off mentors’s
                                                                                                                        Signature: …………………………….

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                                                                                                                          Student Number: ………………………………………

SIGN OFF MENTOR’S EXPECTATIONS AT PRELIMINARY INTERVIEW




JOINT ACTION PLAN FOR PLACEMENT
Identified Objectives (eg what needs to be achieved)                                 Resources/Methods                                Time Scale




Sign off mentor’s Signature: ……………………………………..                                              Student’s Signature: …………………………………………..

Print Name: ………………………………………………..……                                                         Print Name: ……………………………………………………

Date: …………………………………………………………….                                                             Date: …………………………………………………………..


DATE FOR MIDPOINT INTERVIEW: ………………………………                                                  TIME: ……………………
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                                                                                                                Student Number: ………………………………………
MIDPOINT INTERVIEW

Student - Self Assessment:




Sign off mentor’s Assessment:




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                                                                                                                           Student Number: ………………………………………
REVISED ACTION PLAN AT MIDPOINT INTERVIEW

Outstanding/New Objectives                                                           Resources/Methods                                 Time Scale




Sign off mentor’s Signature: ……………………………….                                                            Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                    Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                         Date: …………………………………………………………..


DATE FOR FINAL INTERVIEW: …………………………………                                                               TIME: ………………………

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                                                                                                                                                   Student Number: ………………………………………
FINAL INTERVIEW

Overall comments by student with reference to action plan:




Student’s Signature: .............................................................         Print Name: ................................................................   Date: .................................

Overall comments by sign off mentor(s) with reference to action plan:




Sign off mentor’s Signature: ……………………………….                                                 Print Name: ................................................................   Date: .................................


Associate
Sign off mentor/Midwife’s Signature
(if appropriate):
                           .............................................…..                Print Name: ................................................................   Date: .................................
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                                                                                                                Student Number: ………………………………………

PERSONAL TUTOR INTERVIEW - FOLLOWING COMPLETION OF EACH CLINICAL PLACEMENT

NB:       It is the student’s responsibility to organise the interview following the completion of the clinical placement. It is expected that the students
          will provide their portfolios for discussion.

          PLEASE REMEMBER:
          IT IS EXPECTED THAT YOU WILL MEET UP WITH YOUR PERSONAL TUTOR AT LEAST TWICE IN EACH YEAR.

Clinical Placement:




Portfolio:




Personal Tutor’s
Signature: ………………………………………….                                                     Print Name: …………………………………………….       Date: ............................


Student’s Signature: …………………………………                                               Print Name: ……………………………………………..      Date: ………………………

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                                                                                                                Student Number: ………………………………………

                                                                                                                        ORIENTATION CHECK LIST
STUDENT NAME: ………………………………………………………… STUDENT NO: …………………………..                                                           (to be completed in first
                                                                                                                        week of placement)
                                                                                                                                                         Tick
PRELIMINARY INTERVIEW
                                                                                                                        Layout of clinical area
Placement: …………………………………………………………………………………….

Dates of Allocation: ………………………………………………………………………….                                                                      Policies/Guidelines

Sign off mentor(s): ……………………………………………………………………………                                                                       Bleeps/Emergency bleeps

                              …………………………………………………………………………….                                                            Telephones

                                                                                                                        Call Bell System

Student’s expectations and previous clinical (placement) experience -                                                   Emergency Equipment
(to be completed by the student prior to each placement):-
                                                                                                                        Fire Equipment, Exits
                                                                                                                        and Procedures

                                                                                                                        Procedure in case of personal
                                                                                                                        accident or injury

                                                                                                                        Procedure if student is absent
                                                                                                                        or ill

                                                                                                                        Health and Safety
                                                                                                                        Policies/Procedures

                                                                                                                        Breastfeeding Policies

                                                                                                                        Student’s
                                                                                                                        Signature: …………………………….

                                                                                                                        Sign off mentors’s
                                                                                                                        Signature: …………………………….

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                                                                                                                           Student Number: ………………………………………
SIGN OFF MENTOR’S EXPECTATIONS AT PRELIMINARY INTERVIEW




JOINT ACTION PLAN

Identified Objectives
(what needs to be achieved)                                                          Resources/Methods                                 Time Scale




Sign off mentor’s Signature: ……………………………….                                                            Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                    Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                         Date: …………………………………………………………..


DATE FOR MIDPOINT INTERVIEW: ………………………………                                                             TIME: ……………………

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                                                                                                                Student Number: ………………………………………
MIDPOINT INTERVIEW

Student - Self Assessment:




Sign off mentor’s Assessment:




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                                                                                                                           Student Number: ………………………………………
REVISED ACTION PLAN:

Outstanding/New Objectives                                                           Resources/Methods                                 Time Scale




Sign off mentor’s Signature: ……………………………….                                                            Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                    Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                         Date: …………………………………………………………..


DATE FOR FINAL INTERVIEW: …………………………………                                                               TIME: ………………………

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                                                                                                                                                   Student Number: ………………………………………
FINAL INTERVIEW

Overall comments by student with reference to action plan:




Student’s Signature: .............................................................         Print Name: ................................................................   Date: .................................

Overall comments by Sign off mentor(s) with reference to action plan:




Sign off mentor’s Signature: ……………………………….                                                 Print Name: ................................................................   Date: .................................


Associate
Sign off mentor/Midwife’s Signature
(if appropriate):
                           .............................................…..                Print Name: ................................................................   Date: .................................
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                                                                                                                Student Number: ………………………………………

PERSONAL TUTOR INTERVIEW - FOLLOWING COMPLETION OF EACH CLINICAL PLACEMENT

NB:       It is the student’s responsibility to organise the interview following the completion of the clinical placement. It is expected that the students
          will provide their portfolios for discussion.

          PLEASE REMEMBER:
          IT IS EXPECTED THAT YOU WILL MEET UP WITH YOUR PERSONAL TUTOR AT LEAST TWICE IN EACH YEAR.

Clinical Placement:




Portfolio:




Personal Tutor’s
Signature: ………………………………………….                                                     Print Name: …………………………………………….       Date: ............................


Student’s Signature: …………………………………                                               Print Name: ……………………………………………..      Date: ………………………

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                                                                                                                Student Number: ………………………………………

                                                                                                                        ORIENTATION CHECK LIST
STUDENT NAME: ………………………………………………………… STUDENT NO: …………………………..                                                           (to be completed in first
                                                                                                                        week of placement)
                                                                                                                                                         Tick
PRELIMINARY INTERVIEW
                                                                                                                        Layout of clinical area
Placement: …………………………………………………………………………………….

Dates of Allocation: ………………………………………………………………………….                                                                      Policies/Guidelines

Sign off mentor(s): ……………………………………………………………………………                                                                       Bleeps/Emergency bleeps

                              …………………………………………………………………………….                                                            Telephones

                                                                                                                        Call Bell System

Student’s expectations and previous clinical (placement) experience -                                                   Emergency Equipment
(to be completed by the student prior to each placement):-
                                                                                                                        Fire Equipment, Exits
                                                                                                                        and Procedures

                                                                                                                        Procedure in case of personal
                                                                                                                        accident or injury

                                                                                                                        Procedure if student is absent
                                                                                                                        or ill

                                                                                                                        Health and Safety
                                                                                                                        Policies/Procedures

                                                                                                                        Breastfeeding Policies

                                                                                                                        Student’s
                                                                                                                        Signature: …………………………….

                                                                                                                        Sign off mentors’s
                                                                                                                        Signature: …………………………….

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                                                                                                                           Student Number: ………………………………………
SIGN OFF MENTOR’S EXPECTATIONS AT PRELIMINARY INTERVIEW




JOINT ACTION PLAN

Identified Objectives
(what needs to be achieved)                                                          Resources/Methods                                 Time Scale




Sign off mentor’s Signature: ……………………………….                                                            Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                    Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                         Date: …………………………………………………………..


DATE FOR MIDPOINT INTERVIEW: ………………………………                                                             TIME: ……………………


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                                                                                                                Student Number: ………………………………………
MIDPOINT INTERVIEW

Student - Self Assessment:




Sign off mentor’s Assessment:




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                                                                                                                           Student Number: ………………………………………
REVISED ACTION PLAN:


Outstanding/New Objectives                                                           Resources/Methods                                 Time Scale




Sign off mentor’s Signature: ……………………………….                                                            Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                    Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                         Date: …………………………………………………………..



DATE FOR FINAL INTERVIEW: …………………………………                                                               TIME: ………………………

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                                                                                                                                                   Student Number: ………………………………………
FINAL INTERVIEW

Overall comments by student with reference to action plan:




Student’s Signature: .............................................................         Print Name: ................................................................   Date: .................................

Overall comments by Sign off mentor(s) with reference to action plan:




Sign off mentor’s Signature: ……………………………….                                                 Print Name: ................................................................   Date: .................................


Associate
Sign off mentor/Midwife’s Signature
(if appropriate):
                           .............................................…..                Print Name: ................................................................   Date: .................................
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                                                                                                                Student Number: ………………………………………

PERSONAL TUTOR INTERVIEW - FOLLOWING COMPLETION OF EACH CLINICAL PLACEMENT

NB:       It is the student’s responsibility to organise the interview following the completion of the clinical placement. It is expected that the students
          will provide their portfolios for discussion.

          PLEASE REMEMBER:
          IT IS EXPECTED THAT YOU WILL MEET UP WITH YOUR PERSONAL TUTOR AT LEAST TWICE IN EACH YEAR.

Clinical Placement:




Portfolio:




Personal Tutor’s
Signature: ………………………………………….                                                     Print Name: …………………………………………….       Date: ............................


Student’s Signature: …………………………………                                               Print Name: ……………………………………………..      Date: ………………………

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                                                                                                                       Student Number: ………………………………………
                                                                                                                                   ORIENTATION CHECK LIST
STUDENT NAME: ………………………………………………………… STUDENT NO:                                                                ………………………….. (to be completed in first
                                                                                                                                   week of placement)
                                                                                                                                                          Tick
PRELIMINARY INTERVIEW
                                                                                                                                     Layout of clinical area
Placement: …………………………………………………………………………………….

Dates of Allocation: ………………………………………………………………………….                                                                                   Policies/Guidelines

Sign off mentor(s): ……………………………………………………………………………                                                                                    Bleeps/Emergency bleeps

                              …………………………………………………………………………….                                                                         Telephones

                                                                                                                                     Call Bell System

Student’s expectations and previous clinical (placement) experience -                                                                Emergency Equipment
(to be completed by the student prior to each placement):-
                                                                                                                                     Fire Equipment, Exits
                                                                                                                                     and Procedures

                                                                                                                                     Procedure in case of personal
                                                                                                                                     accident or injury

                                                                                                                                     Procedure if student is absent
                                                                                                                                     or ill

                                                                                                                                     Health and Safety
                                                                                                                                     Policies/Procedures

                                                                                                                                     Breastfeeding Policies

                                                                                                                                     Student’s
                                                                                                                                     Signature: …………………………….

                                                                                                                                     Sign off mentors’s
                                                                                                                                     Signature: …………………………….



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                                                                                                                            Student Number: ………………………………………
SIGN OFF MENTOR’S EXPECTATIONS AT PRELIMINARY INTERVIEW




JOINT ACTION PLAN

Identified Objectives
(what needs to be achieved)                                                          Resources/Methods                                  Time Scale




Sign off mentor’s Signature: ………………………………………                                                          …         Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                    Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                         Date: …………………………………………………………..


DATE FOR MIDPOINT INTERVIEW: ………………………………                                                             TIME: ……………………

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                                                                                                                Student Number: ………………………………………
MIDPOINT INTERVIEW

Student - Self Assessment:




Sign off mentor’s Assessment:




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                                                                                                                            Student Number: ………………………………………
REVISED ACTION PLAN:


Outstanding/New Objectives                                                           Resources/Methods                                  Time Scale




Sign off mentor’s Signature: ………………………………………                                                          …         Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                    Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                         Date: …………………………………………………………..



DATE FOR FINAL INTERVIEW: …………………………………                                                               TIME: ………………………

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                                                                                                                                                   Student Number: ………………………………………
FINAL INTERVIEW

Overall comments by student with reference to action plan:




Student’s Signature: .............................................................         Print Name: ................................................................   Date: .................................

Overall comments by Sign off mentor(s) with reference to action plan:




Sign off mentor’s Signature: ……………………………….                                                 Print Name: ................................................................   Date: .................................


Associate
Sign off mentor/Midwife’s Signature
(if appropriate):
                           .............................................…..                Print Name: ................................................................   Date: .................................
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                                                                                                                Student Number: ………………………………………

PERSONAL TUTOR INTERVIEW - FOLLOWING COMPLETION OF EACH CLINICAL PLACEMENT

NB:       It is the student’s responsibility to organise the interview following the completion of the clinical placement. It is expected that the students
          will provide their portfolios for discussion.

          PLEASE REMEMBER:
          IT IS EXPECTED THAT YOU WILL MEET UP WITH YOUR PERSONAL TUTOR AT LEAST TWICE IN EACH YEAR.

Clinical Placement:




Portfolio:




Personal Tutor’s
Signature: ………………………………………….                                                     Print Name: …………………………………………….       Date: ............................


Student’s Signature: …………………………………                                               Print Name: ……………………………………………..      Date: ………………………

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                                                                                                                Student Number: ………………………………………
THEATRE EXPERIENCE PLACEMENT
                                                                                                                        ORIENTATION CHECK LIST
STUDENT NAME: ………………………………………………………… STUDENT NO: …………………………..                                                           (to be completed in first
                                                                                                                        week of placement)
                                                                                                                                                         Tick
PRELIMINARY INTERVIEW
                                                                                                                        Layout of clinical area
Placement: …………………………………………………………………………………….

Dates of Allocation: ………………………………………………………………………….                                                                      Policies/Guidelines

Sign off mentor(s): ……………………………………………………………………………                                                                       Bleeps/Emergency bleeps

                              …………………………………………………………………………….                                                            Telephones

                                                                                                                        Call Bell System

Student’s expectations and previous clinical (placement) experience -                                                   Emergency Equipment
(to be completed by the student prior to each placement):-
                                                                                                                        Fire Equipment, Exits
                                                                                                                        and Procedures

                                                                                                                        Procedure in case of personal
                                                                                                                        accident or injury

                                                                                                                        Procedure if student is absent
                                                                                                                        or ill

                                                                                                                        Health and Safety
                                                                                                                        Policies/Procedures

                                                                                                                        Breastfeeding Policies

                                                                                                                        Student’s
                                                                                                                        Signature: …………………………….

                                                                                                                        Sign off mentors’s
                                                                                                                        Signature: …………………………….

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                                                                                                                           Student Number: ………………………………………
SIGN OFF MENTORS EXPECTATIONS AT PRELIMINARY INTERVIEW




JOINT ACTION PLAN

Identified Objectives
(what needs to be achieved)                                                          Resources/Methods                                 Time Scale




Sign off mentor’s Signature: ……………………………….                                                            Student’s Signature: …………………………………………..

Print Name: ……………………………………………….. …                                                                    Print Name: ……………………………………………………

Date: ……………………………………………………… …                                                                         Date: …………………………………………………………..


DATE FOR MIDPOINT INTERVIEW: ………………………………                                                             TIME: ……………………

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                                                                                                                                                   Student Number: ………………………………………

FINAL INTERVIEW

Overall comments by student with reference to action plan:




Student’s Signature: .............................................................         Print Name: ................................................................   Date: .................................

Overall comments by Sign off mentor(s) with reference to action plan:




Sign off mentor’s Signature: ……………………………….                                                 Print Name: ................................................................   Date: .................................


Associate
Sign off mentor/Midwife’s Signature
(if appropriate):
                           .............................................…..                Print Name: ................................................................   Date: .................................
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                                                                                                                Student Number: ………………………………………
PERSONAL TUTOR INTERVIEW - FOLLOWING COMPLETION OF EACH CLINICAL PLACEMENT

NB:       It is the student’s responsibility to organise the interview following the completion of the clinical placement. It is expected that the students
          will provide their portfolios for discussion.

          PLEASE REMEMBER:
          IT IS EXPECTED THAT YOU WILL MEET UP WITH YOUR PERSONAL TUTOR AT LEAST TWICE IN EACH YEAR.

Clinical Placement:




Portfolio:




Personal Tutor’s
Signature: ………………………………………….                                                     Print Name: …………………………………………….       Date: ............................


Student’s Signature: …………………………………                                               Print Name: ……………………………………………..      Date: ………………………

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                                                                                                                                    Student Number: ………………………………………
YEAR 2

COMMUNICATION DURING PREGNANCY, LABOUR AND THE POSTNATAL PERIOD
Communicates in a professional manner with women and their families (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Develop and maintain effective communication                                          Achieved                  Date:               Achieved          Date:
with women and their families.                                                                                  Signature:                            Signature:
                                                                                      Not Achieved              Print Name :        Not Achieved      Print Name:

Recognise factors that may affect communication.                                      Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Interpret and respond to identified concerns and                                      Achieved                  Date:               Achieved          Date:
provide appropriate feedback.                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise barriers to effective communication                                         Achieved                  Date:               Achieved          Date:
and respond accordingly.                                                                                        Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Accurately maintain and update relevant written                                       Achieved                  Date:               Achieved          Date:
documentation.                                                                                                  Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Effectively participate in challenging                                                Achieved                  Date:               Achieved          Date:
communication matters eg breaking bad news/                                                                     Signature:                            Signature:
high risk screening result (KSF Core 1).                                              Not Achieved              Print Name:         Not Achieved      Print Name:



NB:       continued on next page

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                                                                                                                                       Student Number: ………………………………………
YEAR 2

COMMUNICATION DURING PREGNANCY, LABOUR AND THE POSTNATAL PERIOD – (continued from previous page)
Communicates in a professional manner with women and their families (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S      RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES      (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Statement                                                         Student to          ASSESSMENT                MENTOR’S SIGNATURE /   RE-ASSESSMENT     MENTOR’S SIGNATURE /
                                                                  provide             (please circle)           DATES                  (please circle)   DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Appreciate the need to communicate with people                                        Achieved                  Date:                  Achieved          Date:
in a manner consistent with their understanding,                                                                Signature:                               Signature:
culture, background and preferred ways of                                             Not Achieved              Print Name:            Not Achieved      Print Name:
communication (KSF Core 1).

Communicate through a variety of multi-media                                          Achieved                  Date:                  Achieved          Date:
channels such as texting.                                                                                       Signature:                               Signature:
                                                                                      Not Achieved              Print Name:            Not Achieved      Print Name:

Discuss with women local/national information to                                      Achieved                  Date:                  Achieved          Date:
assist with making choices including local and                                                                  Signature:                               Signature:
national voluntary agencies and websites.                                             Not Achieved              Print Name:            Not Achieved      Print Name:


Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meetings




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                                                                                                                                    Student Number: ………………………………………
YEAR 2

CULTURAL, POLITICAL AND SOCIOLOGICAL FACTORS
Appreciate the influence of cultural, political and sociological factors on healthcare, promoting the rights of the individual, interests and preferences, beliefs
and customs (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Participate in culturally sensitive care that respects                                Achieved                  Date:               Achieved          Date:
individual rights.                                                                                              Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Discuss ways women and their families have                                            Achieved                  Date:               Achieved          Date:
equality of opportunity to access maternity                                                                     Signature:                            Signature:
services and care.                                                                    Not Achieved              Print Name:         Not Achieved      Print Name:

Discuss the impact of local and national policies                                     Achieved                  Date:               Achieved /        Date:
affecting maternity services.                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meetings




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                                                                                                                                    Student Number: ………………………………………
YEAR 2

EDUCATION AND HEALTH PROMOTION
Contribute to enhancing the health and social wellbeing of women and their families (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Assess the health promotion needs of women and                                        Achieved                  Date:               Achieved          Date:
provide appropriate advice and information.                                                                     Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Provide appropriate health education that is                                          Achieved                  Date:               Achieved          Date:
sensitive to the physical, emotional, spiritual,                                                                Signature:                            Signature:
social and cultural wellbeing of the woman and her                                    Not Achieved              Print Name:         Not Achieved      Print Name:
family.

Incorporate relevant public health policies                                           Achieved                  Date:               Achieved          Date:
pertinent to midwifery care.                                                                                    Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meetings




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                                                                                                                                    Student Number: ………………………………………
YEAR 2

PRACTICE IN ACCORDANCE WITH LEGAL AND ETHICAL REQUIREMENTS RELEVANT TO MIDWIFERY PRACTICE
To appreciate how ethics and law relates to midwifery practice (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Keep accurate and complete records consistent                                         Achieved                  Date:               Achieved          Date:
with current legislation, policy and procedures.                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name :        Not Achieved      Print Name:

Discuss statutory legislation and regulations with                                    Achieved                  Date:               Achieved          Date:
regards to the production, storage, retrieval and                                                               Signature:                            Signature:
destruction of records.                                                               Not Achieved              Print Name:         Not Achieved      Print Name:

Ensure confidentiality and security of information                                    Achieved                  Date:               Achieved          Date:
(written and verbal) and that the principles of data                                                            Signature:                            Signature:
protection are upheld.                                                                Not Achieved              Print Name:         Not Achieved      Print Name:

                                                                                      Achieved                  Date:               Achieved          Date:
*   Adhere with local policies and NMC regulations
                                                                                                                Signature:                            Signature:
in relation to drug administration.                                                   Not Achieved              Print Name:         Not Achieved      Print Name:

Discuss the principles of contemporary ethical                                        Achieved                  Date:               Achieved          Date:
issues and their impact on midwifery practice.                                                                  Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Promote health, safety, eg infection control and                                      Achieved                  Date:               Achieved          Date:
security in the practice environment.                                                                           Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

*   This is further expanded on page 14

NB:       continued on next page
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                                                                                                                                    Student Number: ………………………………………
YEAR 2

PRACTICE IN ACCORDANCE WITH LEGAL AND ETHICAL REQUIREMENTS RELEVANT TO MIDWIFERY PRACTICE – (continued from previous page)
To appreciate how ethics and law relates to midwifery practice (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Practise in accordance with the NMC Code of                                           Achieved                  Date:               Achieved          Date:
Professional Conduct: standards for conduct,                                                                    Signature:                            Signature:
performance and ethics (NMC 2004).                                                    Not Achieved              Print Name:         Not Achieved      Print Name:



Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting




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                                                                                                                                    Student Number: ………………………………………
YEAR 2

MULTI-DISCIPLINARY AND PARTNERSHIP WORKING
Work collaboratively with other disciplines and agencies to ensure women and their families receive optimum care (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Demonstrate the skills of discussion and                                              Achieved                  Date:               Achieved          Date:
negotiation with other disciplines to influence care                                                            Signature:                            Signature:
of the individual woman and her family.                                               Not Achieved              Print Name:         Not Achieved      Print Name:

Engage in the referral process to other disciplines                                   Achieved                  Date:               Achieved          Date:
and agencies.                                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Work collaboratively with other practitioners and                                     Achieved                  Date:               Achieved          Date:
agencies to provide holistic care.                                                                              Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Engage and work effectively as a team member.                                         Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise, respect and engage with the diversity                                      Achieved                  Date:               Achieved          Date:
of professional groups who participate in a                                                                     Signature:                            Signature:
woman’s care (NMC Midwives Rules and                                                  Not Achieved              Print Name:         Not Achieved      Print Name:
Standards 2004).

Promote and encourage women and their families                                        Achieved                  Date:               Achieved          Date:
to contribute to the planning of their care.                                                                    Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting

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                                                                                                                                    Student Number: ………………………………………
YEAR 2

SELF MANAGEMENT
Identify personal learning needs appropriate to a new learner of midwifery (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Take responsibility to identify and meet personal                                     Achieved                  Date:               Achieved          Date:
learning needs.                                                                                                 Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

                                                                                      Achieved                  Date:               Achieved          Date:
*    Establish self-awareness of how personal
                                                                                                                Signature:                            Signature:
attitudes can influence her/his professional role.                                    Not Achieved              Print Name:         Not Achieved      Print Name:
Use appropriate IT skills for obtaining and                                           Achieved                  Date:               Achieved          Date:
recording relevant information in accordance with                                                               Signature:                            Signature:
data protection legislation.                                                          Not Achieved              Print Name:         Not Achieved      Print Name:

Demonstrate efficient organisational skills.                                          Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise the need to share good practice.                                            Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:



*   Failure to achieve this could result in you being referred to the UWE Professional Suitability Panel


Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting

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                                                                                                                                    Student Number: ………………………………………
YEAR 2

PROFESSIONAL QUALITIES
Understand the role of the Midwife in relation to her sphere of practice (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Discuss the framework for statutory supervision of                                    Achieved                  Date:               Achieved          Date:
midwives (Midwives Rules 2004).                                                                                 Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Understand the role of the midwife as lead                                            Achieved                  Date:               Achieved          Date:
professional, incorporating referral processes in                                                               Signature:                            Signature:
situations where there is a deviation from normal                                     Not Achieved              Print Name:         Not Achieved      Print Name:
(Midwives Rules 2004).
Utilise up to date evidence to support practice.                                      Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise the implications of the midwife’s role as                                   Achieved                  Date:               Achieved          Date:
an advocate.                                                                                                    Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise the importance of professional                                              Achieved                  Date:               Achieved          Date:
standards to inform practice,                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Seek and act on constructive feedback in all                                          Achieved                  Date:               Achieved          Date:
aspects of professional practice and behaviour.                                                                 Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting


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                                                                                                                                    Student Number: ………………………………………
YEAR 2

PROFESSIONAL PRACTITIONER / PRACTICE DURING THE ANTENATAL PERIOD
Provide seamless care in partnership with women and other care providers (NICE 2003, NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Utilise knowledge and skills to contribute to the                                     Achieved                  Date:               Achieved          Date:
assessment of maternal and fetal wellbeing and                                                                  Signature:                            Signature:
discuss the interpretation of the findings.                                           Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise when complications in the mother and                                        Achieved                  Date:               Achieved          Date:
fetus occur.                                                                                                    Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Adapt care to meet the needs of a woman with a                                        Achieved                  Date:               Achieved          Date:
complication requiring intervention including                                                                   Signature:                            Signature:
appropriate referral procedures.                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Take appropriate action to summon help and                                            Achieved                  Date:               Achieved          Date:
undertake emergency procedures until help                                                                       Signature:                            Signature:
arrives.                                                                              Not Achieved              Print Name:         Not Achieved      Print Name:

Enable women to address issues about their own                                        Achieved                  Date:               Achieved          Date:
and their family’s health needs in relation to                                                                  Signature:                            Signature:
physical, mental, social and spiritual wellbeing.                                     Not Achieved              Print Name:         Not Achieved      Print Name:

Plan in partnership with women, a care pathway to                                     Achieved                  Date:               Achieved          Date:
ensure individual needs are met.                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting


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                                                                                                                                    Student Number: ………………………………………
YEAR 2

PROFESSIONAL PRACTITIONER / PRACTICE DURING LABOUR
Participate in assessing, planning, implementing and evaluating care given during labour (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Participate in the holistic care and support of                                       Achieved                  Date:               Achieved          Date:
women and their birthing partner during labour.                                                                 Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Participate in the monitoring of the maternal and                                     Achieved                  Date:               Achieved          Date:
fetal conditions during labour using appropriate                                                                Signature:                            Signature:
clinical and technical means.                                                         Not Achieved              Print Name:         Not Achieved      Print Name:

Observe and participate in complicated labours.                                       Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Consider strategies to promote normal birth, whilst                                   Achieved                  Date:               Achieved          Date:
recognising limitations in accordance with safe                                                                 Signature:                            Signature:
practice.                                                                             Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise when complications in the mother                                            Achieved                  Date:               Achieved          Date:
occur and adapt care accordingly.                                                                               Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise when complications in the baby occur                                        Achieved                  Date:               Achieved          Date:
and adapt care accordingly.                                                                                     Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


NB:       continued on next page


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                                                                                                                                    Student Number: ………………………………………
YEAR 2

PROFESSIONAL PRACTITIONER / PRACTICE DURING LABOUR – (continued from previous page)
Participate in assessing, planning, implementing and evaluating care given during labour (NMC 2004)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Take appropriate action to summon help and                                            Achieved                  Date:               Achieved          Date:
undertake emergency procedures until help                                                                       Signature:                            Signature:
arrives.                                                                              Not Achieved              Print Name:         Not Achieved      Print Name:

Rationalise the immediate needs of the newborn                                        Achieved                  Date:               Achieved          Date:
and refer as appropriate.                                                                                       Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

In a culturally sensitive manner, create an                                           Achieved                  Date:               Achieved          Date:
environment that is protective of the maternal                                                                  Signature:                            Signature:
infant attachment process, such as minimal                                            Not Achieved              Print Name:         Not Achieved      Print Name:
handling of the baby, discovering gender, fostering
maternal infant eye contact, skin-to-skin contact.

Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting




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                                                                                                                                    Student Number: ………………………………………
YEAR 2

PROFESSIONAL PRACTITIONER / PRACTICE DURING THE POSTNATAL PERIOD
Be involved with the provision of seamless care in partnership with women and other care providers (NMC 2004, NICE 2006)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Participate in the assessment, planning,                                              Achieved                  Date:               Achieved          Date:
implementation and evaluation of care.                                                                          Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Provide care in partnership with other care                                           Achieved                  Date:               Achieved          Date:
providers for women with complications in the                                                                   Signature:                            Signature:
postnatal period.                                                                     Not Achieved              Print Name:         Not Achieved      Print Name:

Enable women to address issues about their own,                                       Achieved                  Date:               Achieved          Date:
their baby and their family’s health in relation to                                                             Signature:                            Signature:
physical, mental, social and spiritual wellbeing.                                     Not Achieved              Print Name:         Not Achieved      Print Name:

Participate in the referral and care of babies with                                   Achieved                  Date:               Achieved          Date:
specific health and social needs.                                                                               Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise and take appropriate action when a                                          Achieved                  Date:               Achieved          Date:
complication occurs in either the mother and/or                                                                 Signature:                            Signature:
the baby.                                                                             Not Achieved              Print Name:         Not Achieved      Print Name:

Take appropriate action to summon help and                                            Achieved                  Date:               Achieved          Date:
undertake emergency procedures until help                                                                       Signature:                            Signature:
arrives                                                                               Not Achieved              Print Name:         Not Achieved      Print Name:



NB:       continued on next page

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                                                                                                                                    Student Number: ………………………………………
YEAR 2

PROFESSIONAL PRACTITIONER / PRACTICE DURING THE POSTNATAL PERIOD – (continued from previous page)

Be involved with the provision of seamless care in partnership with women and other care providers (NMC 2004, NICE 2006)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Promote the successful transition to parenthood,                                      Achieved                  Date:               Achieved          Date:
appropriate to the needs, contexts and culture of                                                               Signature:                            Signature:
the women, babies and their families                                                  Not Achieved              Print Name:         Not Achieved      Print Name:

Provide nutritional advice and support to women                                       Achieved                  Date:               Achieved          Date:
in relation to feeding new babies.                                                                              Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Actively work with other health professionals to                                      Achieved                  Date:               Achieved          Date:
promote breastfeeding and support women in                                                                      Signature:                            Signature:
their choice to breastfeed.                                                           Not Achieved              Print Name:         Not Achieved      Print Name:



Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting




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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 - ANTENATAL PERIOD

These should be performed under indirect supervision

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Undertake and interpret findings from abdominal                                       Achieved                  Date:               Achieved          Date:
palpation including measurement of symphysis                                                                    Signature:                            Signature:
pubis/fundal height.                                                                  Not Achieved              Print Name:         Not Achieved      Print Name:
Perform an antenatal admission and history                                            Achieved                  Date:               Achieved          Date:
taking.                                                                                                         Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:
Auscultation of the fetal heart using:-                                               Achieved                  Date:               Achieved          Date:
    Pinard / Doppler                                                                                           Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:
         Cardiotocograph                                                             Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:
Assist with inductions of labour.                                                     Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:
Calculate the Bishops score.                                                          Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:
Undertake and interpret biochemical,                                                  Achieved                  Date:               Achieved          Date:
haematological and pathological investigations.                                                                 Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:
Undertake pre-operative preparation, for example                                      Achieved                  Date:               Achieved          Date:
elective caesarean section.                                                                                     Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting


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                                                                                                                Student Number: ………………………………………




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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 - INTRAPARTUM PERIOD

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Support a woman and her partner in labour.                                            Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assess progress of labour and acknowledge when                                        Achieved                  Date:               Achieved          Date:
deviations occur.                                                                                               Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


Auscultate and interpret the fetal heart rate using                                   Achieved                  Date:               Achieved          Date:
    Pinard / Doppler                                                                                           Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

          Cardiotocograph                                                            Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Perform and begin to correctly interpret vaginal                                      Achieved                  Date:               Achieved          Date:
examinations.                                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Palpate uterine contractions and correctly interpret                                  Achieved                  Date:               Achieved          Date:
findings.                                                                                                       Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


NB:       continued on next page




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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 - INTRAPARTUM PERIOD – (continued from previous page)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Promote a variety of birthing positions and                                           Achieved                  Date:               Achieved          Date:
mobilisation.                                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assist with caring for a woman undergoing                                             Achieved                  Date:               Achieved          Date:
augmentation of labour.                                                                                         Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assist with the administration and caring for                                         Achieved                  Date:               Achieved          Date:
women with epidural/spinal anaesthesia.                                                                         Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assist with instrumental births.                                                      Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assist with IV cannulation (simulation).                                              Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Safely Perform female catheterisation.                                                Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Monitor, manage and document fluid balance.                                           Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


NB:       Continued on next page
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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 - INTRAPARTUM PERIOD – (continued from previous page)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Participate in managing a breech labour/birth                                         Achieved                  Date:               Achieved          Date:
(simulation).                                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Participate in managing a multiple labour/birth                                       Achieved                  Date:               Achieved          Date:
(simulation).                                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Participate in managing a pre-term labour/ birth.                                     Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assist in caring for a woman with a history of                                        Achieved                  Date:               Achieved          Date:
previous caesarean section.                                                                                     Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assist in caring for a woman with diabetes in                                         Achieved                  Date:               Achieved          Date:
labour (simulation).                                                                                            Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assist in caring for a woman with pre-                                                Achieved                  Date:               Achieved          Date:
eclampsia/eclampsia (simulation) including                                                                      Signature:                            Signature:
medicines management.                                                                 Not Achieved              Print Name:         Not Achieved      Print Name:

Assist in caring for a woman with a post partum                                       Achieved                  Date:               Achieved          Date:
haemorrhage including medicines management.                                                                     Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


NB:       continued on next page

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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – INTRAPARTUM PERIOD – (continued from previous page)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Perform infiltration of the perineum (simulation).                                    Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Perform an episiotomy (simulation).                                                   Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Observe/participate in perineal suturing.                                             Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Perform neonatal resuscitation (simulation).                                          Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Provide information and obtain consent for                                            Achieved                  Date:               Achieved          Date:
appropriate administration of vitamin K to the                                                                  Signature:                            Signature:
neonate                                                                               Not Achieved              Print Name:         Not Achieved      Print Name:

Demonstrate the role of the midwife in the theatre                                    Achieved                  Date:               Achieved          Date:
environment.                                                                                                    Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting




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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – POSTNATAL PERIOD

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Explore with women the potential impact of                                            Achieved                  Date:               Achieved          Date:
delivery room practices eg different pain relief                                                                Signature:                            Signature:
methods, skin-to-skin contact, on the wellbeing of                                    Not Achieved              Print Name:         Not Achieved      Print Name:
their baby and themselves and on the
establishment of breast feeding in particular.
Advise on breast feeding in accordance with the                                       Achieved                  Date:               Achieved          Date:
Baby Friendly Initiative including the importance of                                                            Signature:                            Signature:
exclusive breastfeeding.                                                              Not Achieved              Print Name:         Not Achieved      Print Name:

Participate in positioning and attachment for                                         Achieved                  Date:               Achieved          Date:
breast feeding.                                                                                                 Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Participate in supporting a woman expressing                                          Achieved                  Date:               Achieved          Date:
breast milk.                                                                                                    Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Understand the importance of community support                                        Achieved                  Date:               Achieved          Date:
for breast feeding and refer women to appropriate                                                               Signature:                            Signature:
support networks.                                                                     Not Achieved              Print Name:         Not Achieved      Print Name:

Discuss with women the importance of exclusive                                        Achieved                  Date:               Achieved          Date:
breast feeding for six months and timely                                                                        Signature:                            Signature:
introduction of complementary foods.                                                  Not Achieved              Print Name:         Not Achieved      Print Name:

Participate in individualised advice on formula                                       Achieved                  Date:               Achieved          Date:
feeding.                                                                                                        Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

NB:       Continued on next page

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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – POSTNATAL PERIOD – (continued from previous page)

UNDER INDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Participate in sterilisation of equipment for breast                                  Achieved                  Date:               Achieved          Date:
and formula feeding.                                                                                            Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Provide advice and manage common breast                                               Achieved                  Date:               Achieved          Date:
feeding complications.                                                                                          Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Provide parents with information on sudden infant                                     Achieved                  Date:               Achieved          Date:
death syndrome.                                                                                                 Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Undertake a normal neonatal postnatal                                                 Achieved                  Date:               Achieved          Date:
examination.                                                                                                    Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Undertake a normal maternal postnatal                                                 Achieved                  Date:               Achieved          Date:
examination.                                                                                                    Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Support and promote the transition to parenthood.                                     Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise and document the signs of an unwell                                         Achieved                  Date:               Achieved          Date:
neonate.                                                                                                        Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


NB:       continued on next page

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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – POSTNATAL PERIOD - (continued from previous page)

UNDER UNDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Recognise maternal infection and plan care                                            Achieved                  Date:               Achieved          Date:
appropriately.                                                                                                  Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise maternal haemorrhage and plan care                                          Achieved                  Date:               Achieved          Date:
appropriately                                                                                                   Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise maternal haematological disorders.                                          Achieved                  Date:               Achieved          Date:
and plan care appropriately                                                                                     Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise maternal thrombosis and plan care                                           Achieved                  Date:               Achieved          Date:
appropriately.                                                                                                  Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Recognise abnormal responses in relation to                                           Achieved                  Date:               Achieved          Date:
maternal mental health wellbeing.                                                                               Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Assess women at risk of thromboembolic                                                Achieved                  Date:               Achieved          Date:
disorders and administer prophylaxis eg ante-                                                                   Signature:                            Signature:
embolic stocking, hydration.                                                          Not Achieved              Print Name:         Not Achieved      Print Name:



NB:       continued on next page




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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – POSTNATAL PERIOD - (continued from previous page)

UNDER UNDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Safely remove an indwelling catheter.                                                 Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Safely remove an intravenous infusion.                                                Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        ® Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting




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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – NEONATAL / TRANSITIONAL CARE SKILLS

UNDER UNDIRECT SUPERVISION: Is able to:

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Communicate and support parents.                                                      Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Support women who are separated from their                                            Achieved                  Date:               Achieved          Date:
babies to initiate and maintain their lactation and                                                             Signature:                            Signature:
feed their babies optimally                                                           Not Achieved              Print Name:         Not Achieved      Print Name:

Prevent cross-infection.                                                              Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Monitor neonatal blood glucose levels.                                                Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Care for neonates in incubators.                                                      Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Maintain neonatal thermoregulation.                                                   Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Feed expressed breast milk to a baby, using a cup                                     Achieved                  Date:               Achieved          Date:
and/or syringe as appropriate.                                                                                  Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


NB:       Continued on next page

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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 - NEONATAL / TRANSITIONAL CARE SKILLS – (continued from previous page)

UNDER UNDIRECT SUPERVISION: Is able to:

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Care for pre-term neonates                                                            Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Care for growth restricted neonates.                                                  Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Monitor and care for neonates with jaundice.                                          Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Monitor and care for neonates with respiratory                                        Achieved                  Date:               Achieved          Date:
complications.                                                                                                  Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Monitor the growth and development of neonates.                                       Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Liaise with the multi-disciplinary team.                                              Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Have involvement with discharge and follow-up                                         Achieved                  Date:               Achieved          Date:
care.                                                                                                           Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting
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                                                                                                                                   Student Number: ………………………………………

SKILLS FOR YEAR 2 - THEATRE AND RECOVERY EXPERIENCE

UNDER INDIRECT SUPERVISION:                        Is able to:-


STATEMENT                                                         Student to         ASSESSMENT                 SIGN OFF MENTORS   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  Provide            (please circle)            SIGNATURE / DATE   (please circle)   SIGNATURE / DATE
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Participate in the provision of care for the                                         Achieved                   Date:              Achieved          Date:
unconscious patient                                                                                             Signature:                           Signature:
                                                                                     Not Achieved               Print Name:        Not Achieved      Print Name:

Participate in the provision of immediate care for                                   Achieved                   Date:              Achieved          Date:
the patient following surgery                                                                                   Signature:                           Signature:
                                                                                     Not Achieved               Print Name:        Not Achieved      Print Name:




Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting




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                                                                                                                Student Number: ………………………………………




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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – DRUG ADMINISTRATION

UNDER UNDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Demonstrate confidence in accessing commonly                                          Achieved                  Date:               Achieved          Date:
used evidence based sources of information                                                                      Signature:                            Signature:
relating to the safe and effective management of                                      Not Achieved              Print Name:         Not Achieved      Print Name:
medicinal products.
Participate in drug checking procedures.                                              Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Participate in drug calculations (**)                                                 Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Identify and justify appropriate routes of drug                                       Achieved                  Date:               Achieved          Date:
administration (**)                                                                                             Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Report adverse incidents and near misses and                                          Achieved                  Date:               Achieved          Date:
adverse drug reactions.                                                                                         Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Under supervision safely and effectively select,                                      Achieved                  Date:               Achieved          Date:
acquire and administer medicinal products via the                                                               Signature:                            Signature:
following routes:-                                                                    Not Achieved              Print Name:         Not Achieved      Print Name:
      Oral preparations.


(**)      Summative health related assessments are required to test skills identified (**) within the ECSs that encompass calculations associated
          with medicines. A 100% pass mark is required and assessment must take place in the practice setting.

NB:       Continued on next page
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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – DRUG ADMINISTRATION - (continued from previous page)


UNDER UNDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
         Intramuscular preparations.                                                 Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

         Per rectum preparations.                                                    Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

         Per vaginum preparations.                                                   Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

         Intravenous infusion (simulation).                                          Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

         Sub-cutaneous (simulation).                                                 Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

         Topical (simulation).                                                       Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

         Inhalation                                                                  Achieved                  Date:               Achieved          Date:
                                                                                                                Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


NB:       continued on next page
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                                                                                                                                    Student Number: ………………………………………
SKILLS FOR YEAR 2 – DRUG ADMINISTRATION - (continued from previous page)


UNDER UNDIRECT SUPERVISION: Is able to:-

Statement                                                         Student to          ASSESSMENT                SIGN OFF MENTOR’S   RE-ASSESSMENT     SIGN OFF MENTOR’S
                                                                  provide             (please circle)           SIGNATURE / DATES   (please circle)   SIGNATURE / DATES
                                                                  Sources of
                                                                  Evidence
                                                                  (key below)
Use prescription charts correctly and maintain                                        Achieved                  Date:               Achieved          Date:
accurate records.                                                                                               Signature:                            Signature:
                                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:

Demonstrate an understanding of medicines                                             Achieved                  Date:               Achieved          Date:
management from a multi-disciplinary team                                                                       Signature:                            Signature:
perspective.                                                                          Not Achieved              Print Name:         Not Achieved      Print Name:

Ensure information sharing is woman-centred and                                       Achieved                  Date:               Achieved          Date:
provides clear and accurate information so                                                                      Signature:                            Signature:
women can make informed choices about their                                           Not Achieved              Print Name:         Not Achieved      Print Name:
medicinal products.
Assess a woman’s ability to self-administer                                           Achieved                  Date:               Achieved          Date:
medicinal products and provide clear explanation                                                                Signature:                            Signature:
as to their use.                                                                      Not Achieved              Print Name:         Not Achieved      Print Name:


Sources of Evidence Key:                (RK) Record Keeping (O) Observation (MD) Mentor Discussion (MW) Multi-disciplinary Working (S) Simulation
                                        (R) Reflection (Res) Research (PG) Policies/Guidelines (PA) Peer Assessment (UA) User Assessment (M) Meeting




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                                                                                                                Student Number: ………………………………………




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                                                                                                                            Student Number: ………………………………………
SOURCES OF EVIDENCE

The following list provides a key and explanation for sources of evidence that are used to support the achievement of the proficiencies. It is expected that the student will
document their evidence according to each statement.

(RK)      Record Keeping:
          A written record that promotes communication between health care team and between practitioners and their patients and clients (NMC, 2005)

(O)       Observation:
          Has been observed undertaking the skill/task.

(MD)      Sign off mentor Discussion:
          A communication process which supports learning and enables the student to meet the NMC proficiencies.

(MW)      Multi-disciplinary Working:
          A team that includes health and social care workers inclusive of the independent and voluntary sectors eg attendance at a case conference, team meetings.

(S)       Simulation:
          A representation of reality where real actions and real consequences can be performed and observed

(R)       Reflection:
          When an individual is able to analyse an experience in order to create a new understanding.

(Res)     Research:
          Collection and analysis of data to create the evidence to help support practice

(PG)      Policies/ Guidelines:
          Knowledge of related policies and guidelines e.g NICE

(PA)      Peer Assessment/Feedback:
          The assessment/feedback of students by other students

(UA)      User Assessment/Feedback:
          Actively seeking feedback from women, their families or carers if appropriate, to contribute to the assessment.

(M)       Meetings:
          Attending meetings, case conferences, in-house study days.



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                                                                                                                Student Number: ………………………………………




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                                                                                                                  Student Number: ………………………………………
DISCUSSION SURROUNDING ISSUES RELATING TO STUDENT’S PROGRESS

This discussion may be initiated by the student, sign off mentor or personal tutor at anytime during the course

A copy of these pages should be included in the student’s portfolio

Issue/discussion




Student’s signature: ……………………………………………                                                     Print Name: ……………………………………... Date: ………………………………

Mentor’s signature: ……………………………………………                                                      Print Name: ……………………………………… Date: ………………………………

Tutor informed (print): ……………………………………….                                                                                Date: ………………………………


REVIEW DATE: ………………………………………………                                                            TIME: …………………………        ACTION PLAN REQUIRED YES / NO
                                                                                                                   (see next page)
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                                                                                                                     Student Number: ………………………………………


 DATE               ISSUE                       ACTION PLAN (if required)                                       DATE OF       SIGN OFF
                                                                                                                REVIEW        MENTOR AND
                                                                                                                              STUDENT




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                                                                                                                  Student Number: ………………………………………

REVIEW:




Student’s signature: ……………………………………………                                                     Print Name: ……………………………………... Date: ………………………………


Sign off mentor’s signature : …………………………………… Print Name: ……………………………………… Date: ………………………………

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                                                                                                                Student Number: ………………………………………




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                                                                                                                  Student Number: ………………………………………
DISCUSSION SURROUNDING ISSUES RELATING TO STUDENT’S PROGRESS

This discussion may be initiated by the student, sign off mentor or personal tutor at anytime during the course

A copy of these pages should be included in your portfolio

Issue/discussion




Student’s signature: ……………………………………………                                                     Print Name: ……………………………………... Date: ………………………………

Sign off mentor’s signature : …………………………………… Print Name: ……………………………………… Date: ………………………………

Tutor informed (name): ……………………………………….                                                    Print Name: ……………………………………… Date: ………………………………


REVIEW DATE: ……………………………………………….                                                           TIME: …………………………        ACTION PLAN REQUIRED YES / NO
                                                                                                                   (see next page)

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                                                                                                                     Student Number: ………………………………………


 DATE               ISSUE                       ACTION PLAN (if required)                                       DATE OF       SIGN OFF
                                                                                                                REVIEW        MENTOR AND
                                                                                                                              STUDENT




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                                                                                                                  Student Number: ………………………………………

REVIEW:




Student’s signature: ……………………………………………                                                     Print Name: ……………………………………... Date: ………………………………


Sign off mentor’s signature : ……………………………………Print Name: ………………………………………                                                 Date: ………………………………

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                                                                                                                Student Number: ………………………………………




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                                                                                                                  Student Number: ………………………………………
DISCUSSION SURROUNDING ISSUES RELATING TO STUDENT’S PROGRESS

This discussion may be initiated by the student, sign off mentor or personal tutor at anytime during the course

A copy of these pages should be included in your portfolio

Issue/discussion




Student’s signature: ……………………………………………                                                     Print Name: ……………………………………... Date: ………………………………

Sign off mentor’s signature : …………………………………… Print Name: ……………………………………… Date: ………………………………

Tutor informed (name): ……………………………………….                                                    Print Name: ……………………………………… Date: ………………………………


REVIEW DATE: ………………………………………………                                                            TIME: ………………………….       ACTION PLAN REQUIRED YES / NO
                                                                                                                   (see next page)
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                                                                                                                     Student Number: ………………………………………


 DATE               ISSUE                       ACTION PLAN (if required)                                       DATE OF       SIGN OFF
                                                                                                                REVIEW        MENTOR AND
                                                                                                                              STUDENT




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                                                                                                                  Student Number: ………………………………………

REVIEW:




Student’s signature: ……………………………………………                                                     Print Name: ……………………………………... Date: ………………………………


Sign off mentor’s signature : ……………………………………Print Name: ………………………………………                                                 Date: ………………………………

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                                                                                                                Student Number: ………………………………………




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                                                                                                                  Student Number: ………………………………………
DISCUSSION SURROUNDING ISSUES RELATING TO STUDENT’S PROGRESS

This discussion may be initiated by the student, sign off mentor or personal tutor at anytime during the course

A copy of these pages should be included in your portfolio

Issue/discussion




Student’s signature: ……………………………………………                                                     Print Name: ……………………………………... Date: ………………………………

Sign off mentor’s signature : ……………………………………Print Name: ………………………………………                                                 Date: ………………………………

Tutor informed (name): ……………………………………….                                                    Print Name: ……………………………………… Date: ………………………………


REVIEW DATE: ……………………………………………….                                                           TIME: ………………………..       ACTION PLAN REQUIRED YES / NO
                                                                                                                   (see next page)
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                                                                                                                     Student Number: ………………………………………


 DATE               ISSUE                       ACTION PLAN (if required)                                       DATE OF       SIGN OFF
                                                                                                                REVIEW        MENTOR AND
                                                                                                                              STUDENT




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                                                                                                                  Student Number: ………………………………………

REVIEW:




Student’s signature: ……………………………………………                                                     Print Name: ……………………………………... Date: ………………………………


Sign off mentor’s signature : …………………………………… Print Name: ……………………………………… Date: ………………………………

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                                                                                                                Student Number: ………………………………………




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                                                                                                                Student Number: ………………………………………
YEAR 2 – SIGN-OFF MENTOR SUMMARY SHEET
For completion at the END of the FINAL placement, both pages to be completed in addition to final interview documentation.


Name of Student: ……………………………………………………………………………. Student No: ………………………….

Student’s evaluation of the year:




Student Signature: …………………………………………………………………………… Date: …………………………………




Name of Sign-off Mentor: …………………………………………………………………..
Sign-off mentor’s comments on student’s knowledge and professional attributes:




Strengths:




Areas for development:




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                                                                                                                Student Number: ………………………………………




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                                                                                                                Student Number: ………………………………………

Achievement of NMC Proficiencies for Year 2




                                               Achieved / Not Achieved - (please delete as appropriate)




Sign-off Mentor Signature: …………………………………….................


Print Name: …………………………………………………………………..


Position held: ………………………………………………………………..


Hospital Name and Department: …………………………………………………


Date: ……………………………….



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                                                                                                                Student Number: ………………………………………




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                                                                                                                                             Student Number: ………………………………………
YEAR 2 – FINAL PLACEMENT - FOR COMPLETION BY STUDENT PRIOR TO PERSONAL TUTOR INTERVIEW

Record of EU Midwifery Directive numbers to date:                      Nos to Date                              Mandatory Requirements                     Date(s)
Number of antenatal examinations                                                                                Manual Handling 1 - Date attended
Witnessed deliveries                                                                                            CPR 1 – Date attended
Supervision and care of at least 40 women in labour                                                             Neonatal Resuscitation 1 – Date attended
Personal deliveries                                                                                             Numeracy Test                              Achieved / Not achieved
Witnessed episiotomies
Supervision and care of women at risk during
- antenatal period
- labour
- postnatal period
Postnatal examinations
Attendance at clinics (please state which clinics)

Self-declaration of continuing good health and character (in accordance with NMC guidelines):

Student’s Name:………………………………………………………………………………………………………..

Students Signature: …………………………………………………………..                                              Date: ………………………………


Personal Tutor’s comments:-
Student’s knowledge, skills and professional attributes:



Clinical Placements:



Portfolio:



Personal Tutor’s Signature: ……………………………………………                                       Personal Tutor’s Name (print): ………………………………………… Date: ……………......................



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                                                                                                                       Student Number: ………………………………………
                                                       PRACTICE ASSOCIATE LECTURERS IN MIDWIFERY (PALM’s)


AREA                                               PALM                                               TEL NO          EMAIL

BATH                                               Mary Mitchell                                      0117 32 88892   Mary.Mitchell@uwe.ac.uk
 (including Paulton, Frome                         Caroline Rutter                                    0117 32 88798   Caroline.Rutter@uwe.ac.uk
and Shepton Mallett


CHELTENHAM AND
GLOUCESTER                                         Kathleen Baird                                     0117 32 88776   Kathleen2.Baird@uwe.ac.uk
(including Stroud and                              Sue Davis                                          0117 32 88639   Susan.Davis@uwe.ac.uk
Forest of Dean)

NBT                                                Jenny Hall                                         0117 32 88586   Jenny.Hall@uwe.ac.uk
                                                   Sheena Payne                                       0117 32 88578   Sheena.Payne@uwe.ac.uk
                                                   Helen Francomb                                     0117 9595050
                                                                                                      ext 4212/6274   Helen.Francomb@nbt.nhs.uk


SWINDON                                            Kirsten Baker                                      0117 32 88539   Kirsten.Baker@uwe.ac.uk
(including Trowbridge,                             Dorothy Cook                                       0117 32 88587   Dorothy.Cook@uwe.ac.uk
Malmesbury, Devizes)                               Susan Tucker                                       01793 604732    Susan2.Tucker@uwe.ac.uk
and Chippenham


UHbristol                                          Geraldine Lucas                                    0117 32 88519   Geraldine.Lucas@uwe.ac.uk
                                                   Julie Williams                                     0117 32 88562   Julie.Williams@uwe.ac.uk


WESTON                                             Julie Hobbs                                        0117 32 88579   Julie.Hobbs@uwe.ac.uk

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                                                                                                                Student Number: ………………………………………




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                                                                                                                Student Number: ………………………………………




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                                                                                                                Student Number: ………………………………………




If found please return to:

University of the West of England
Faculty of Health and Life Sciences
Department of Nursing and Midwifery
Glenside Campus
Blackberry Hill
Stapleton
Bristol BS16 1DD

Telephone:          0117 32 88457
Fax:                0117 32 88411




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