CLEMSON UNIVERSITY School of Nursing Preceptor Evaluation Form Student_ Carolyn Schmutz Course_0140 _ Total hours with students 33 + 25) Please “X” if this isa Midterm Evaluation x inal Evaluation Preceptor Name (please print): Poanele_ Sacksos> Practice Name/Address/Telephone/Practice or Personal ba a ec eas Color 43S Me Miler PQ lems, $C_9963¢- Preceptor: Please complete this final clinical evaluation form for the student you are precepting. The preceptor’s input into the asscssment of the student’s level of achievement is an integral component of this course. You are encouraged to iscuss your assessment, suggestions, and recommendations with the student, If you have questions or need further explanation or clarification, please contact the faculty member. Please assess performance by circling the one appropriate number using the following scale: *1=unsafe practice; 2=below expected level; 3= at expected level; 4= above expected level; S=outstanding —N/A= not applicable or insufficient information/opportunity to evaluate, For any unsafe practice — immediately notify course instructor History Takir Tas TENA Complete, concise, relevant, organized and accurate 1 234)s5 WA rite time used sical ination 243) IVA Appropriate, complete (age, gender, development and cultural aspects), organized 12.3 4 (S)NA Appropriate tine wed ‘Skillful with procedures! diagnostic tests; List those observed: 123 4 (57NA Complete relevant, organized 123 4 (DNA Utiization ofsubjectvelobjective information 123 4 © WA Setsheakh cae priorities 12.3 4 OWA teen tae N/A __ Accurately deter Verbal case sentation to preceptor pee N/A Synthesis of history 1 23 (4)5 NA synopsis opty ox and ny tags tein inling peta egies 123 OE WA Consideration of management st tives Patient Management WA Documents accurately and efficiently in health record NA Formulates therapeuti plen N/A Incorporates health teaching and counseling, ee Gs eae a ese ete 123 «wa Selects appropriate pharmacologic therapy | EEEement (continued) JS N/A Incorporates non-pharmacologic care (physical therapy, occupational, holistic interven 23.4 N/A_Includes follow-up plans 123 «GWA. Reps etn 12 2@s NVA. Relicves anxiety; answers questions 123 0 (S) N/A Involves paleo in health cae planing 1 2 3 4 (5) N/A Communicates on patients’ level NA Preceptor(s) and Staff Elicits patient feelings, attitudes, concerns 12 VA. Demonstrates positive attitude 12 3. 4 [5 )NVA Contributes positively to work environmen interdisciptinary team 1 2 3 4 (5).NA Responsible, dependable, respectful feedback 123 4(S) WA Accepts nd responds to const 1234 (BWA __ Exhibits self-control Confidence Y203 4(s) wa skin 1 2.3 4 (5) NA settdirectea 1 2 3 4/5) NA Shows initiative 23 4 5 NA 123 4 5 NA 123 4 5 NA 2 3 4/5 )wa_ Please provide an overall rating Summary Comments: [0/306 vemeasal Wrastterdaclin HP pe om [5 ‘Agni, thank you for yotr assistance In comping this evaluation, Plnse give form Ga sealed envelope tote student to hand deliver tothe Sehool of Nrsing offs [Fapm may also be faxed (othe oie at 864-250-6711. Please contact the eee at 864-250-6702 for ny questions or concerns