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Newman University Nurse Anesthesia Program Student Clinical Evaluation Form

Student Clinical Evaluation

FOR IMMEDIATE CONCERNS, please reach out to Thomas Watson, Clinical Director: watsont@newmanu.edu

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* 1. Student Name:

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* 2. Clinical Instructor Name:

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* 3. Clinical Instructor's Email:

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* 4. Practicum:

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* 5. Clinical Area or Specialty Rotation

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* 6. 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, demonstrates understanding of specialty anesthesia principals, analyzes the specialty patient history& physical status & plans appropriate anesthesia (Regional or General). Provides patient education & informed consent.	1. Planning & Assessment: Student is able to assess patient status, demonstrates understanding of specialty anesthesia principals, analyzes the specialty patient history& physical status & plans appropriate anesthesia (Regional or General). Provides patient education & informed consent. 5	1. Planning & Assessment: Student is able to assess patient status, demonstrates understanding of specialty anesthesia principals, analyzes the specialty patient history& physical status & plans appropriate anesthesia (Regional or General). Provides patient education & informed consent. 4	1. Planning & Assessment: Student is able to assess patient status, demonstrates understanding of specialty anesthesia principals, analyzes the specialty patient history& physical status & plans appropriate anesthesia (Regional or General). Provides patient education & informed consent. 3	1. Planning & Assessment: Student is able to assess patient status, demonstrates understanding of specialty anesthesia principals, analyzes the specialty patient history& physical status & plans appropriate anesthesia (Regional or General). Provides patient education & informed consent. 2	1. Planning & Assessment: Student is able to assess patient status, demonstrates understanding of specialty anesthesia principals, analyzes the specialty patient history& physical status & plans appropriate anesthesia (Regional or General). Provides patient education & informed consent. 1	1. Planning & Assessment: Student is able to assess patient status, demonstrates understanding of specialty anesthesia principals, analyzes the specialty patient history& physical status & plans appropriate anesthesia (Regional or General). Provides patient education & informed consent. N/A
2. Induction: Student selects appropriate drugs, positions patient for optimal physiologic function, performs planned regional/general anesthetic with understanding of underlying specialty principles. Emergency equipment available.	2. Induction: Student selects appropriate drugs, positions patient for optimal physiologic function, performs planned regional/general anesthetic with understanding of underlying specialty principles. Emergency equipment available. 5	2. Induction: Student selects appropriate drugs, positions patient for optimal physiologic function, performs planned regional/general anesthetic with understanding of underlying specialty principles. Emergency equipment available. 4	2. Induction: Student selects appropriate drugs, positions patient for optimal physiologic function, performs planned regional/general anesthetic with understanding of underlying specialty principles. Emergency equipment available. 3	2. Induction: Student selects appropriate drugs, positions patient for optimal physiologic function, performs planned regional/general anesthetic with understanding of underlying specialty principles. Emergency equipment available. 2	2. Induction: Student selects appropriate drugs, positions patient for optimal physiologic function, performs planned regional/general anesthetic with understanding of underlying specialty principles. Emergency equipment available. 1	2. Induction: Student selects appropriate drugs, positions patient for optimal physiologic function, performs planned regional/general anesthetic with understanding of underlying specialty principles. Emergency equipment available. N/A
3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters, monitors level & effectivementss of regional blocks, demonstrates appropriate management of the general anesthetic. Appropriate dosing & sequencing of required medications specific to that patient population.	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters, monitors level & effectivementss of regional blocks, demonstrates appropriate management of the general anesthetic. Appropriate dosing & sequencing of required medications specific to that patient population. 5	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters, monitors level & effectivementss of regional blocks, demonstrates appropriate management of the general anesthetic. Appropriate dosing & sequencing of required medications specific to that patient population. 4	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters, monitors level & effectivementss of regional blocks, demonstrates appropriate management of the general anesthetic. Appropriate dosing & sequencing of required medications specific to that patient population. 3	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters, monitors level & effectivementss of regional blocks, demonstrates appropriate management of the general anesthetic. Appropriate dosing & sequencing of required medications specific to that patient population. 2	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters, monitors level & effectivementss of regional blocks, demonstrates appropriate management of the general anesthetic. Appropriate dosing & sequencing of required medications specific to that patient population. 1	3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters, monitors level & effectivementss of regional blocks, demonstrates appropriate management of the general anesthetic. Appropriate dosing & sequencing of required medications specific to that patient population. N/A
4. Emergence: Student times emergence of GA with completion of surgical procedure, insuring patient ability to maintain airway. Doses/redoeses with appropriate medications. Evaluates levels and recovery needs of specialty patient.	4. Emergence: Student times emergence of GA with completion of surgical procedure, insuring patient ability to maintain airway. Doses/redoeses with appropriate medications. Evaluates levels and recovery needs of specialty patient. 5	4. Emergence: Student times emergence of GA with completion of surgical procedure, insuring patient ability to maintain airway. Doses/redoeses with appropriate medications. Evaluates levels and recovery needs of specialty patient. 4	4. Emergence: Student times emergence of GA with completion of surgical procedure, insuring patient ability to maintain airway. Doses/redoeses with appropriate medications. Evaluates levels and recovery needs of specialty patient. 3	4. Emergence: Student times emergence of GA with completion of surgical procedure, insuring patient ability to maintain airway. Doses/redoeses with appropriate medications. Evaluates levels and recovery needs of specialty patient. 2	4. Emergence: Student times emergence of GA with completion of surgical procedure, insuring patient ability to maintain airway. Doses/redoeses with appropriate medications. Evaluates levels and recovery needs of specialty patient. 1	4. Emergence: Student times emergence of GA with completion of surgical procedure, insuring patient ability to maintain airway. Doses/redoeses with appropriate medications. Evaluates levels and recovery needs of specialty patient. N/A
5. Transport: Student transports the specialty patient, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. Recognizes & treats potential complications associated with the specialty patient.	5. Transport: Student transports the specialty patient, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. Recognizes & treats potential complications associated with the specialty patient. 5	5. Transport: Student transports the specialty patient, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. Recognizes & treats potential complications associated with the specialty patient. 4	5. Transport: Student transports the specialty patient, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. Recognizes & treats potential complications associated with the specialty patient. 3	5. Transport: Student transports the specialty patient, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. Recognizes & treats potential complications associated with the specialty patient. 2	5. Transport: Student transports the specialty patient, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. Recognizes & treats potential complications associated with the specialty patient. 1	5. Transport: Student transports the specialty patient, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. Recognizes & treats potential complications associated with the specialty patient. N/A
6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs regional blocks with assistance as necessary & demonstrates progressive improvement in ability to perform blocks.	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs regional blocks with assistance as necessary & demonstrates progressive improvement in ability to perform blocks. 5	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs regional blocks with assistance as necessary & demonstrates progressive improvement in ability to perform blocks. 4	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs regional blocks with assistance as necessary & demonstrates progressive improvement in ability to perform blocks. 3	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs regional blocks with assistance as necessary & demonstrates progressive improvement in ability to perform blocks. 2	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs regional blocks with assistance as necessary & demonstrates progressive improvement in ability to perform blocks. 1	6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs regional blocks with assistance as necessary & demonstrates progressive improvement in ability to perform blocks. N/A
7. Reliability: Student carries out assignments, relieves 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, relieves 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, relieves 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, relieves 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, relieves 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, relieves 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, relieves at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families. N/A
8. Equipment Safety: Student performs a daily check of the anesthesia machine, and identifies and takes appropriate action when confronted with anesthetic equipment-related malfunctions.	8. Equipment Safety: Student performs a daily check of the anesthesia machine, and identifies and takes appropriate action when confronted with anesthetic equipment-related malfunctions. 5	8. Equipment Safety: Student performs a daily check of the anesthesia machine, and identifies and takes appropriate action when confronted with anesthetic equipment-related malfunctions. 4	8. Equipment Safety: Student performs a daily check of the anesthesia machine, and identifies and takes appropriate action when confronted with anesthetic equipment-related malfunctions. 3	8. Equipment Safety: Student performs a daily check of the anesthesia machine, and identifies and takes appropriate action when confronted with anesthetic equipment-related malfunctions. 2	8. Equipment Safety: Student performs a daily check of the anesthesia machine, and identifies and takes appropriate action when confronted with anesthetic equipment-related malfunctions. 1	8. Equipment Safety: Student performs a daily check of the anesthesia machine, and identifies and takes appropriate action when confronted with anesthetic equipment-related malfunctions. N/A

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* 7. Personal Safety: Follows Universal Precautions.

Yes

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

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

Yes

NO - Please specify

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* 9. Character Skills - Important: Please rate the student on how well they demonstrated the following Important 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	N/A
1. Plans Effectively	1. Plans Effectively 5	1. Plans Effectively 4	1. Plans Effectively 3	1. Plans Effectively 2	1. Plans Effectively 1	1. Plans Effectively N/A
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	2. Works with Appropriate Speed N/A
3. Communicates Effectively	3. Communicates Effectively 5	3. Communicates Effectively 4	3. Communicates Effectively 3	3. Communicates Effectively 2	3. Communicates Effectively 1	3. Communicates Effectively N/A
4. Adaptable/Flexible	4. Adaptable/Flexible 5	4. Adaptable/Flexible 4	4. Adaptable/Flexible 3	4. Adaptable/Flexible 2	4. Adaptable/Flexible 1	4. Adaptable/Flexible N/A
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	5. Performs Well Under Stress N/A

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* 10. The SRNA delivers care that is considerate of the cultural needs of the patient, showing sensitivity and utilizing resources available to deliver culturally competent care.

Met

Unmet

Needs Improvement

If selecting Unmet or Needs Improvement, please comment.

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* 11. Did you discuss this evaluation with the student?

Yes

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* 1. Student Name:

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* 2. Clinical Instructor Name:

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* 3. Clinical Instructor's Email:

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* 4. Practicum:

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* 5. Clinical Area or Specialty Rotation

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* 6. 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

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* 7. Personal Safety: Follows Universal Precautions.

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

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* 10. The SRNA delivers care that is considerate of the cultural needs of the patient, showing sensitivity and utilizing resources available to deliver culturally competent care.

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* 11. Did you discuss this evaluation with the student?

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* 12. Areas Needing Improvement and/or Strengths