School of Nursing Preceptor Evaluation Form Student_ A. ten rernckt Course SZ _ Total hours with student: BOW, Please “X” if this is a Midterm Eval or Final Evaluation _ >< receptor Name (please print)R.\Ciek Practice Name/Address/Telephone/Practice or Personal Email; Fors qi Pe Siotdess -Levacreutc. Preceptor: Please complete this final clinical evaluation form for the student you are precepting, The preceptor's input into the assessinent of the student’s level of achievement is an integral component of this course. You are encouraged to discuss your assessment, suggestions, and recommendations with the student. If you hiave questions or need further explanation or clarification, please contact the faculty member. Please assess performance by circling the one appropriate number using the following seale: *1 = unsafe practice; 2= below expected level; 3= at expected level; 4= above expected level; 5=outstanding N/A = not applicable or insufficient information/opportunity to evaluate. For any unsafe practice ~ immediately notify course instructor History Taki Pony 4 CP WA Complete, condi, tlovan,omanized and accurate 2s 2 © wa supra tinoues Physical Examination Toad 1 CES WA" _Approotiat,conplte ees, sonder, development and ara espests,cguizad 12.3 4 @ WA Appropriate time used 234 (SNA _ skillful with procedures diagnostic tests; List those observed: L Clinical Judgment T2343) NA Complete event organized 1 2. 3 4 B WA Uilization of subjectivelobjective 1 2 3. 4 GWA Seisheatth care priorities 123 4 © WA teenies citerenial diagnoses 123 4 B WA _ Accurately determines final diagnoses Verbal case presentation to preceptor 12 3 4(3) NA Synthesis offistory 1 2 3 4 [9 NA Synopsis of physical exam and any diagnostic testing including pertinent negatives 123 4 © wa consideration of mage’ ateraives Patient Mausam fi 123 4 5 Documents accurately and efficiently in health record 12 3 4 @ NA Fomultes therapeutic plan Seater at CO wa Incorporates health teaching and counseling 1 2 3 4 @ NA Addresses applicabie health promotion’ prevention 1 2 3 4 (3) NA Selects approprite pharmacologic therapy Over>>>Patient Management (continu T 2 3 4(3 NA Incorporates non-pharmacologic care (physical therapy, occupational, holistic interventions) 12 3. 4) NA Refes or mental heath counseling and specialty cre 12 3 4 Q WA _ Includes follow-up plans Rapport with Patient / Family 1 2 3 4C¥ NA Blicits patient confidence and cooperation 123 40) WA Respect, kind enstive 123 4B) NA Relves anxiety; nsers questions 1203 4 () NA. totes pens ce pig 12 3 4G _NA Communicates on patients eve 1234 (SNA _Bilicits patent feelings, attitudes, concerns Relationship with Preceptor(s) and Staff To? 3-4 C3) NA Denne postive aide 12 3 4 @® NA Contributes positively to work environment interdscplinary team 12 3 4 (5> NA Responsible, dependable, sespectful 1 2 3 4d NA Accepts and responds to constructive fedback 123 _ 4 Q)_NA_ Fehibits seltcontrol pace Confidence 12 3 4CS> NA skits 123 7) NIA Selfivected 123 ACJ NA Shows iniatve Pas 405 NA 123 4G wa Please provide an overall ratin; Summary Comments: Bll. Crsatot Preceptor signature: CAL dh wD) pas /2: pace ‘Again, thank you for your assistance in completing this evaluation. Please give form (in sealed envejope) to Ahe student to hhand deliver to the School of Nursing office, Form may also be faxed (0 the office at 864-250-6711, Please contact the office at 864-250-6702 for any questions or concerns,