Clinical Performance Evaluation Form printable pdf download

Clinical Performance Evaluation Form

CLINICAL PERFORMANCE EVALUATION FORM

The faculty liaison, in collaboration with the student’s preceptor will evaluate the student based

on the following criteria at the completion of the practicum. Each evaluation will be assessed

according to the following performance criteria:

4 – Exemplary – Meets and exceeds expected standards consistently

3 – Competent – Meets expected standards*

2 – Fair – Meets expected standards inconsistently

1 – Inadequate – Does not meet expected standards

ANY INADEQUATE RATING WILL RESULT IN COUNSELING, AND

POSSIBLE FAILURE OF PRACTICUM.

*ALL competencies under Course/Program Outcome #3 must be performed at a

competent level or better to successfully complete the program.

The total score represents 30% of the student’s final grade.

Student_____________________Facility/Unit__________________Date___________

Preceptor__________________________________________

Faculty Liaison______________________________________

Please write the score for each objective on the line provided.

Course/Program Outcome #1

Interact appropriately through verbal, nonverbal, and written communication with

patients, families, and members of the health care team.

1.1) Utilize effective communication skills when interacting with clients, significant others, and

healthcare team.

_____

1.2) Communicate relevant, accurate and complete information in a concise and clear

manner.

_____

1.3) Report and document assessments, interventions and progress toward client

outcomes.

_____

1.4) Utilize appropriate channels of communication to achieve positive client

outcomes.

_____

1.5) Utilize information technology to support and communicate the planning and

provision of client care.

_____

1.6) Delineate and maintain appropriate professional boundaries in the nurse-client

relationship.

_____

NU: Sp ’13 Adopted. July ‘13 REV.

Clinical Performance Evaluation Form