Student Name: Date:

Evaluator Name:

Scoring Key: 0 = step omitted/does not meet competency 1 =

partially wrong/approaching competency 2 =
accurate performance/competent

SKILL PEER SELF INSTR.

Importa
nt: All
patient
assessment
s and
findings
are to be
verbalized
along with
their
performan
ce
Student displays 0 1 2 0 1 2 0 1 2
professionalism
1
(
a
p
p
r
o
p
r
i
a
t
e

n
e
a
t
/

c
l
e
a
n

s
c
h
o
o
l

u
n
i
f
o
r
m
,

n
a
m
e

t
a
g

v
i
s
i
b
l
e
,

h
a
i
r

p
u
l
l
e
d

b
a
c
k

a
n
d

u
p
,

n
a
i
l
s

a
r
e

t
r
i
m
 m
e
d

s
h
o
r
t

w
i
t
h

n
o

p
o
l
i
s
h
/
a
c
r
y
l
i
c
s
,

n
o

j
e
w
e
l
r
y
,

e
t
c
.
)

I 0 1 2 0 1 2 0 1 2
2
n
t
r
o
d
u
c
e

s
e
l
f
,

c
o
n
f
i
r
m

c
l
i
e
n
t

i
d
e
n
t
i
t
y

u
s
i
n
g

t
h
r
e
e

p
a
t
i
e
n
t

i
d
e
n
t
i
f
i
e
r
s
,

e
x
p
l
 a
i
n

p
r
o
c
e
d
u
r
e

Hand hygiene, 0 1 2 0 1 2 0 1 2
3
provide privacy

C 0 1 2 0 1 2 0 1 2
4 o
n
s
i
d
e
r
s

e
r
g
o
n
o
m
i
c
s

a
n
d

s
e
t
s

u
p

f
o
r

a
s
s
e
s
s
m
e
n
t
 a
p
p
r
o
p
r
i
a
t
e
l
y
.

A 0 1 2 0 1 2 0 1 2
5 s
s
e
s
s
e
s

a
p
p
e
a
r
a
n
c
e

a
n
d

c
o
g
n
i
t
i
o
n

o
f

p
a
t
i
e
n
t

(
p
o
s
 i
t
i
o
n
,

s
e
l
f
-
c
a
r
e
,

s
p
e
e
c
h

a
r
t
i
c
u
l
a
t
i
o
n
)

Performs vital 0 1 2 0 1 2 0 1 2
signs
6
(
T
e
m
p
e
r
a
t
u
r
e
,

B
/
P
,

P
u
l
s
 e
,

R
e
s
p
i
r
a
t
i
o
n
s

&

O
2

s
a
t
u
r
a
t
i
o
n
)

A 0 1 2 0 1 2 0 1 2
s
s
7
e
s
s

p
a
t
i
e
n
t

p
a
i
n

l
e
v
e
l
:

A
s
k
s
p
a
t
i
e
n
t

a
b
o
u
t

p
a
i
n
U
s
e
s

t
h
e

a
p
p
r
o
p
r
i
a
t
e

e
x
p
l
a
n
a
t
i
o
n

o
f

p
a
i
n

s
c
a
l
e
 u
s
e
d

t
o

e
n
s
u
r
e

o
p
t
i
m
a
l

e
v
a
l
u
a
t
i
o
n

o
f

p
a
t
i
e
n
t
’
s

p
a
i
n

l
e
v
e
l

Performs 0 1 2 0 1 2 0 1 2
neurological
8
assessment:
(
L
O
C
,

o
r
i
e
n
t
a
t
i
o
n
,

P
E
R
R
L
A
,

f
a
c
i
a
l

s
y
m
m
e
t
r
y
,

e
q
u
a
l

h
a
n
d

g
r
i
p
s
,

m
o
v
e
s
 a
l
l

e
x
t
r
e
m
i
t
i
e
s

e
q
u
a
l
l
y
)

Performs 0 1 2 0 1 2 0 1 2
cardiovascular
assessment:
9
(
a
p
i
c
a
l

p
u
l
s
e
,

h
e
a
r
t

s
o
u
n
d
s
,

b
i
l
a
t
e
r
a
l

c
o
m
p
a
r
i
s
o
n

o
f

r
a
d
i
a
l

p
u
l
s
e
,

p
u
l
s
e

r
e
g
u
l
a
r

o
r

i
r
r
e
g
u
l
a
r
,

c
a
p
i
l
l
a
r
y

r
e
f
i
l
l
,

p
e
d
a
l

p
u
l
s
e
s

(
c
o
m
p
a
r
e

b
i
l
a
t
e
r
a
l
l
y
)
,

c
a
l
f

t
e
n
d
e
r
n
e
s
s
,

p
 e
r
i
p
h
e
r
a
l

e
d
e
m
a
)

P 0 1 2 0 1 2 0 1 2
e
r
10
f
o
r
m
s

r
e
s
p
i
r
a
t
o
r
y

a
s
s
e
s
s
m
e
n
t
:

(
a
u
s
c
u
l
t
a
t
e
s

a
l
l

l
u
n
g

f
i
e
l
d
s

a
n
t
e
r
i
o
r
l
y

a
n
d

p
o
s
t
e
r
i
o
r
l
y

u
s
i
n
g

z
i
g
-
z
a
g

t
e
c
h
n
i
q
u
e
,

p
r
e
s
e
n
c
e

o
f

c
o
u
g
h
,

r
e
s
p
i
r
a
t
o
r
y

r
h
y
t
h
m

a
n
d

d
e
p
t
h
,

o
x
y
g
e
n

t
h
e
r
a
p
y
 ,

S
O
B
)

P 0 1 2 0 1 2 0 1 2
e
r
11 f
o
r
m
s

g
a
s
t
r
o
i
n
t
e
s
t
i
n
a
l

a
s
s
e
s
s
m
e
n
t
:

(
a
u
s
c
u
l
t
a
t
e
s

b
o
w
e
l

s
o
u
n
d
s

R
L
Q
-
R
U
Q
-
L
U
Q
-
L
L
Q
,

a
b
d
o
m
e
n

s
h
a
p
e
,

p
a
l
p
a
t
e

f
o
r

t
e
n
d
e
r
n
e
s
s
-

l
i
g
h
t

a
n
d

d
e
e
p
,

l
a
s
t

B
M

d
a
t
e
,

q
u
a
n
t
i
t
y
,

c
o
n
s
i
s
t
e
n
c
y
,

c
o
l
o
r
,

c
o
n
t
i
n
 e
n
c
e
,

d
i
e
t
,

o
r
a
l

c
a
v
i
t
y

m
u
c
o
s
a
,

t
e
e
t
h
,

s
w
a
l
l
o
w
i
n
g
)

Performs 0 1 2 0 1 2 0 1 2
genitourinary
11
assessment:
(urin
e
output
–
color,
quanti
ty,
contin
ence,
burni
ng,
 itchin
g,
vagin
al/pen
ile
discha
rge,
disten
tion)

P 0 1 2 0 1 2 0 1 2
e
12 r
f
o
r
m
s

m
u
s
c
u
l
o
s
k
e
l
e
t
a
l

a
s
s
e
s
s
m
e
n
t

(
a
r
m

s
t
r
e
n
g
t
h

a
n
d
l
e
g

s
t
r
e
n
g
t
h

w
i
t
h

b
i
l
a
t
e
r
a
l

c
o
m
p
a
r
i
s
o
n
,

g
a
i
t
,

R
O
M

a
n
d

i
n
s
p
e
c
t

j
o
i
n
t

a
r
e
a
s

a
n
d

p
a
l
p
a
t
i
o
n

o
f

b
o
n
y

a
r
t
i
c
u
l
a
t
i
o
n
s
,

s
w
e
l
l
i
n
g
,

c
r
e
p
i
t
u
s
,
 p
a
i
n
)

P 0 1 2 0 1 2 0 1 2
e
13 r
f
o
r
m
s

i
n
t
e
g
u
m
e
n
t

a
s
s
e
s
s
m
e
n
t
:

t
h
i
s

a
s
s
e
s
s
m
e
n
t

m
a
y

b
e

d
o
n
e

w
h
i
l
e

c
o
n
d
u
c
t
i
n
g

o
t
h
e
r

b
o
d
y

s
y
s
t
e
m

a
s
s
e
s
s
m
e
n
t
s
(
c
o
l
o
r
,

t
e
m
p
e
r
a
t
u
 r
e
,

m
o
i
s
t
u
r
e
,

l
e
s
i
o
n
s
,

e
d
e
m
a
,

i
t
c
h
i
n
g
,

n
u
m
b
n
e
s
s
)
0 1 2
Upon completion 0 1 2 0 1 2
of assessments:
Communicates
to the patient
14 that they are
finished with
assessment
and when they
may return

Asks if patient
requires anything
or assistance before
leaving

Lowers bed
 and returns
side table if
relocated for
assessment,
call bell use
articulated to
patient and
placed within
patient reach

Effective and 0 1 2 0 1 2 0 1 2
15
clear
communication
techniques
used
throughout
assessments

Additional
Comments:

TOTAL
SCORE: