Newman University Nurse Anesthesia Program Student Clinical Evaluation Form
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1. Student Name:

Student Name:

2. Instructor Name:

Instructor Name:

3. Instructor Email Address:

Instructor Email Address:

The following evaluation shall reflect the level of the graduate student relative to the behavioral objectives while they are on specific clinical rotations. Indicate clinical area & appropriate response to the evaluation.

4. Clinical Practicum:

Clinical Practicum:

5. Type of Anesthesia:

Type of Anesthesia: General

MAC

Regional

Monitoring

6. Clinical Area:

Clinical Area:

7. Rating Scale: 5 - No assistance required; 4 - Minimal assistance required; 3 - Appropriate assistance required for level; 2 - Extensive assistance OR did not understand theory after explanation; 1 - Could not perform without assistance.

	5	4	3	2	1	N/A
1. Planning & Assessment: Student is able to assess patient status, formulate care plan, demonstrate accurate knowledge, write appropriate orders, select, set-up & implement suitable monitoring. Plans appropriate regional.	*Rating Scale: 5 - No assistance required; 4 - Minimal assistance required; 3 - Appropriate assistance required for level; 2 - Extensive assistance OR did not understand theory after explanation; 1 - Could not perform without assistance. 1. Planning & Assessment: Student is able to assess patient status, formulate care plan, demonstrate accurate knowledge, write appropriate orders, select, set-up & implement suitable monitoring. Plans appropriate regional. 5	1. Planning & Assessment: Student is able to assess patient status, formulate care plan, demonstrate accurate knowledge, write appropriate orders, select, set-up & implement suitable monitoring. Plans appropriate regional. 4	1. Planning & Assessment: Student is able to assess patient status, formulate care plan, demonstrate accurate knowledge, write appropriate orders, select, set-up & implement suitable monitoring. Plans appropriate regional. 3	1. Planning & Assessment: Student is able to assess patient status, formulate care plan, demonstrate accurate knowledge, write appropriate orders, select, set-up & implement suitable monitoring. Plans appropriate regional. 2	1. Planning & Assessment: Student is able to assess patient status, formulate care plan, demonstrate accurate knowledge, write appropriate orders, select, set-up & implement suitable monitoring. Plans appropriate regional. 1	1. Planning & Assessment: Student is able to assess patient status, formulate care plan, demonstrate accurate knowledge, write appropriate orders, select, set-up & implement suitable monitoring. Plans appropriate regional. N/A
2. Induction: Student selects appropriate drugs/techniques, follows steps of induction & adjusts technique as necessary, recognizes & maintains patent airway, follows through with post-induction assessment, & intraoperative management. Performs regional with necessary assistance & assesses results.	2. Induction: Student selects appropriate drugs/techniques, follows steps of induction & adjusts technique as necessary, recognizes & maintains patent airway, follows through with post-induction assessment, & intraoperative management. Performs regional with necessary assistance & assesses results. 5	2. Induction: Student selects appropriate drugs/techniques, follows steps of induction & adjusts technique as necessary, recognizes & maintains patent airway, follows through with post-induction assessment, & intraoperative management. Performs regional with necessary assistance & assesses results. 4	2. Induction: Student selects appropriate drugs/techniques, follows steps of induction & adjusts technique as necessary, recognizes & maintains patent airway, follows through with post-induction assessment, & intraoperative management. Performs regional with necessary assistance & assesses results. 3	2. Induction: Student selects appropriate drugs/techniques, follows steps of induction & adjusts technique as necessary, recognizes & maintains patent airway, follows through with post-induction assessment, & intraoperative management. Performs regional with necessary assistance & assesses results. 2	2. Induction: Student selects appropriate drugs/techniques, follows steps of induction & adjusts technique as necessary, recognizes & maintains patent airway, follows through with post-induction assessment, & intraoperative management. Performs regional with necessary assistance & assesses results. 1	2. Induction: Student selects appropriate drugs/techniques, follows steps of induction & adjusts technique as necessary, recognizes & maintains patent airway, follows through with post-induction assessment, & intraoperative management. Performs regional with necessary assistance & assesses results. N/A
3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters of patient status, observes surgical field & relates to anesthetic considerations & complications, identifies ventilatory & fluid resuscitation needs. Monitors regional level & effectiveness.	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters of patient status, observes surgical field & relates to anesthetic considerations & complications, identifies ventilatory & fluid resuscitation needs. Monitors regional level & effectiveness. 5	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters of patient status, observes surgical field & relates to anesthetic considerations & complications, identifies ventilatory & fluid resuscitation needs. Monitors regional level & effectiveness. 4	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters of patient status, observes surgical field & relates to anesthetic considerations & complications, identifies ventilatory & fluid resuscitation needs. Monitors regional level & effectiveness. 3	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters of patient status, observes surgical field & relates to anesthetic considerations & complications, identifies ventilatory & fluid resuscitation needs. Monitors regional level & effectiveness. 2	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters of patient status, observes surgical field & relates to anesthetic considerations & complications, identifies ventilatory & fluid resuscitation needs. Monitors regional level & effectiveness. 1	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters of patient status, observes surgical field & relates to anesthetic considerations & complications, identifies ventilatory & fluid resuscitation needs. Monitors regional level & effectiveness. N/A
4. Emergence: Times emergence with completion of surgery, follows proper sequencing for extubation, evaluates & maintains patent airway post-extubation/emergence. Evaluates progression & level of regional.	4. Emergence: Times emergence with completion of surgery, follows proper sequencing for extubation, evaluates & maintains patent airway post-extubation/emergence. Evaluates progression & level of regional. 5	4. Emergence: Times emergence with completion of surgery, follows proper sequencing for extubation, evaluates & maintains patent airway post-extubation/emergence. Evaluates progression & level of regional. 4	4. Emergence: Times emergence with completion of surgery, follows proper sequencing for extubation, evaluates & maintains patent airway post-extubation/emergence. Evaluates progression & level of regional. 3	4. Emergence: Times emergence with completion of surgery, follows proper sequencing for extubation, evaluates & maintains patent airway post-extubation/emergence. Evaluates progression & level of regional. 2	4. Emergence: Times emergence with completion of surgery, follows proper sequencing for extubation, evaluates & maintains patent airway post-extubation/emergence. Evaluates progression & level of regional. 1	4. Emergence: Times emergence with completion of surgery, follows proper sequencing for extubation, evaluates & maintains patent airway post-extubation/emergence. Evaluates progression & level of regional. N/A
5. Transport: Students transports the patient to the PACU, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel.	5. Transport: Students transports the patient to the PACU, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. 5	5. Transport: Students transports the patient to the PACU, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. 4	5. Transport: Students transports the patient to the PACU, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. 3	5. Transport: Students transports the patient to the PACU, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. 2	5. Transport: Students transports the patient to the PACU, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. 1	5. Transport: Students transports the patient to the PACU, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. N/A
6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs, regional blocks with assistance as necessary, inserts LMA's, manages & ventilates mask cases.	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs, regional blocks with assistance as necessary, inserts LMA's, manages & ventilates mask cases. 5	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs, regional blocks with assistance as necessary, inserts LMA's, manages & ventilates mask cases. 4	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs, regional blocks with assistance as necessary, inserts LMA's, manages & ventilates mask cases. 3	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs, regional blocks with assistance as necessary, inserts LMA's, manages & ventilates mask cases. 2	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs, regional blocks with assistance as necessary, inserts LMA's, manages & ventilates mask cases. 1	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs, regional blocks with assistance as necessary, inserts LMA's, manages & ventilates mask cases. N/A
7. Reliability: Student carries out assignments, releives at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families.	7. Reliability: Student carries out assignments, releives at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families. 5	7. Reliability: Student carries out assignments, releives at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families. 4	7. Reliability: Student carries out assignments, releives at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families. 3	7. Reliability: Student carries out assignments, releives at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families. 2	7. Reliability: Student carries out assignments, releives at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families. 1	7. Reliability: Student carries out assignments, releives at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families. N/A

8. Personal Safety: Follows Universal Precautions.

Personal Safety: Follows Universal Precautions. Yes

No - Please specify (eye wear, gloves, etc.)

9. Did the student demonstrate the Essential Character Skills: Honesty, Punctuality & Eagerness to Learn?

Did the student demonstrate the Essential Character Skills: Honesty, Punctuality & Eagerness to Learn? Yes

No - Please specify

10. Character Skills - Important:
Please rate the student on how well they demonstrated the following Imporant Character Skills. Rating Scale: 5 - Exceptional use of skill; 4 - Above average use of skill; 3 - Average use of skill; 2 - Needed direction pertaining to skill; 1 - Needs immediate assistance with skill.

	5	4	3	2	1
1. Plans Effectively	*Character Skills - Important: Please rate the student on how well they demonstrated the following Imporant Character Skills. Rating Scale: 5 - Exceptional use of skill; 4 - Above average use of skill; 3 - Average use of skill; 2 - Needed direction pertaining to skill; 1 - Needs immediate assistance with skill. 1. Plans Effectively 5	1. Plans Effectively 4	1. Plans Effectively 3	1. Plans Effectively 2	1. Plans Effectively 1
2. Works with Appropriate Speed	2. Works with Appropriate Speed 5	2. Works with Appropriate Speed 4	2. Works with Appropriate Speed 3	2. Works with Appropriate Speed 2	2. Works with Appropriate Speed 1
3. Communicates Effectively	3. Communicates Effectively 5	3. Communicates Effectively 4	3. Communicates Effectively 3	3. Communicates Effectively 2	3. Communicates Effectively 1
4. Adaptable/Flexible	4. Adaptable/Flexible 5	4. Adaptable/Flexible 4	4. Adaptable/Flexible 3	4. Adaptable/Flexible 2	4. Adaptable/Flexible 1
5. Performs Well Under Stress	5. Performs Well Under Stress 5	5. Performs Well Under Stress 4	5. Performs Well Under Stress 3	5. Performs Well Under Stress 2	5. Performs Well Under Stress 1

11. Did you discuss this evaluation with the student?

Did you discuss this evaluation with the student? Yes

12. Areas Needing Improvement and/or Strengths:

Areas Needing Improvement and/or Strengths:

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Newman University Nurse Anesthesia Program Student Clinical Evaluation FormExit this survey

Newman University Nurse Anesthesia Program Student Clinical Evaluation Form
Exit this survey