CLEMSON School of Nursing Preceptor Evaluation Form ~ Spring 2016 student Cocolyn Sch mute Please “X” if this is 1 Midterm Evaluation Preceptor Name (please print): ‘ Practice Name/Address/Telephone/Practice and Email: urse: 8230 Total hours with student: _ 5S or Fjnal Evalu: Preceptor: Please complete this final clinical evaluation form for the student you are precepting. The preceptor’s input into the assessment of the students 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 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 sc: *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 Takinj T 2 3 @ 5 NIA Complete, concise, relevant, organized and accurate 123 @)5_NA__ Appropriate time used Physical Examination 12 3 @ 5 NA Appropriate, complete (age, gender, development and cultural aspects), organized 1 2 8 Qs WA sepropnsienen Tea. 5_N/A__ Skillful with procedures’ diagnostic tests; List those observed: ¢. injechonS, trigger Clinical Judgment point injec#ions, mele Pemnoval, 1 2 3G) 5 N/A Complete,rclevant, organized YS Femeual, 14D, X-rays 123 @) 5 NA __ Utilization ofsubjective/objectve information 1 2 3 (5 NA Setshealth cae provties 1 2 3 @ 5 WA Identifies differential diagnoses, 12 3 @5_NA Accurately determines final diagnoses ‘Verbal case presentation to preceptor 1234 G) NA Synthesis ofhistory Fe Ca are es alee ce ae ae eae ee a Patient Management 1 2 3 G5 NIA Documents accurately and efficiently in health record 12 3 @ 5 WA Formulates therapeu plan 12-34 QA tmcoponts th easing on comslng t@aepa © N/A Addresses applicable health promotion/ prevention 1 2 3C3) 5 NIA Selects appropriate pharmacologic therapy Over>>>|Patient Management (continued) 123 5 N/A__ Incorporates non-pharmacologic care (physical therapy, occupational, holistic interventions) 1 2 QBS NA. Refers formetl hath ousting sn sci 123 4 GNA Insert aln Rapport with Patient / Family 23. 4 @) NA _ Elicits patient confidence and cooperation 123. 4G NA Respect kind, sensitive 12.3. 4 @ NA Retoves anxiety; answers questions 123. 4 @ NA _Inmolves patient in health cate planing noo 48 N/A Communicates on patients’ level 123 4@Q WA 5 atiudes, concerns Relationship with Preceptor(s) and Staff 1 2 3 4 () NA Demonstrates positive atitude 123. 4 Q NA Contributes postvly to work envionment interdsspinry team 1 2. 3 4 Q WA Responsible dependable, respect 123 4 @ WA Accepts and responds to constructive fecdback 234 Q_NA __ Exhibits self-control 1 Confidens Por s I NA sui 123 4 Qywa saeco 123 4 PNA Shows initiative 123 4 5 NA 123 4 5 NA 123 4 5 NA 1 2 3 4 5 wA_ Please provide an overall rating ‘Summary Comments: releieees | SDL AC vae afayly ‘Again, thank you for your assistance in completing this evaluation. Please give form (in sealed envelope) to the student to hand deliver to the School of Nursing office. Form may also be faxed to the office at 864-250-6711. Please contact the office at 864-250-6702 for any questions or concerns.