Sample Clinical Teacher Report Form printable pdf download

SAMPLE CLINICAL TEACHER REPORT FORM

Learner ________________________________________________ Date __________________________

Preceptor _______________________________________ Course/Module ________________________

Site __________________________________________________________________________________

The following format is to be used to evaluate learner progress at set intervals (telephone contact,

clinical faculty meetings, etc.).

A. Follows Each Step of Management or Clinical Decision Making Process

1. Collects complete data in timely manner

2. Makes correct decisions based on data collected

3. Recognizes emergency need for action (priority setting)

4. Assumes appropriate role in setting (learner, consultant, etc.)

5. Designs comprehensive plan with alternatives

6. Implements plan safely and efficiently

7. Evaluates effects of interventions appropriately

B. Clinical Skills Development

1. Hand skills: appropriate timing, accurate results, minimal discomfort to patient

2. Communication skills: clear, concise, complete, and accurate oral presentations to

preceptor/consultant: appropriate client teaching and instructions given; legible,

complete and concise written records

3. Theory base appropriate to level of learner

C. Professional Behaviors

1. Accountable – responsible, dependable, and practices in accord with standards and

policies; able to accurately evaluate own performance

2. Commitment to philosophy of care of APN or midwifery discipline (patient

autonomy, competence, family centered care)

3. Demonstrates initiative and self-direction – accepts constructive criticisms, new

ideas and concepts, leadership potential

D. Overall Performance Relative to Expectations (Outcomes)

E. Summary of Strengths and Needs

Used with permission from:

Thompson, JE, Kershbaumer, RM & Krisman-Scott, MA. (2001). Educating Advanced Practice

Nurses and Midwives: From Practice to Teaching. Philadelphia. Springer Publishing Company.

Sample Clinical Teacher Report Form