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Periodic Evaluation: Tracking Progression To Independent Practice

Evaluate the level of capability at specific intervals during the orientation and internship period. All ratings will be based on, and reflect PROGRESSION towards, the individual’s ability to INDEPENDENTLY MANAGE A FULL PATIENT ASSIGNMENT.

“Limited experience” ratings include any aspects of care that have NOT yet been observed and validated, along with any concerns that require further supervision.

Scores of 4, 5 or 6 show strong, effective, skills development and progression towards independent management of a full assignment.

A rating of 7 or higher indicates the ability to function and prioritize without supervision, assistance or direction.

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* 1. Week you are evaluating:

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* 2. User ID (optional except for Nevada grant participants)

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* 3. Your role:

I am a Preceptor

I am a new grad Intern - RN

I am a "new to specialty" Intern - RN

I am a new grad Intern - LPN

I am a "new to specialty" Intern - LPN

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* 4. Year this data falls in:

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* 5. Time period this data applies to:

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* 6. Agency Name

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* 7. Safety/Technical/Clinical Skills- in the Management of a FULL Patient Assignment

	1 - Limited Experience	2	3	4	5	6	7	8	9	10 - Completely Independent
Maintains universal precautions	Maintains universal precautions 1 - Limited Experience	Maintains universal precautions 2	Maintains universal precautions 3	Maintains universal precautions 4	Maintains universal precautions 5	Maintains universal precautions 6	Maintains universal precautions 7	Maintains universal precautions 8	Maintains universal precautions 9	Maintains universal precautions 10 - Completely Independent
Safety for self and patients - body mechanics, emergencies	Safety for self and patients - body mechanics, emergencies 1 - Limited Experience	Safety for self and patients - body mechanics, emergencies 2	Safety for self and patients - body mechanics, emergencies 3	Safety for self and patients - body mechanics, emergencies 4	Safety for self and patients - body mechanics, emergencies 5	Safety for self and patients - body mechanics, emergencies 6	Safety for self and patients - body mechanics, emergencies 7	Safety for self and patients - body mechanics, emergencies 8	Safety for self and patients - body mechanics, emergencies 9	Safety for self and patients - body mechanics, emergencies 10 - Completely Independent
Assessment and planning	Assessment and planning 1 - Limited Experience	Assessment and planning 2	Assessment and planning 3	Assessment and planning 4	Assessment and planning 5	Assessment and planning 6	Assessment and planning 7	Assessment and planning 8	Assessment and planning 9	Assessment and planning 10 - Completely Independent
General procedures and interventions	General procedures and interventions 1 - Limited Experience	General procedures and interventions 2	General procedures and interventions 3	General procedures and interventions 4	General procedures and interventions 5	General procedures and interventions 6	General procedures and interventions 7	General procedures and interventions 8	General procedures and interventions 9	General procedures and interventions 10 - Completely Independent
IV and medication management	IV and medication management 1 - Limited Experience	IV and medication management 2	IV and medication management 3	IV and medication management 4	IV and medication management 5	IV and medication management 6	IV and medication management 7	IV and medication management 8	IV and medication management 9	IV and medication management 10 - Completely Independent

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* 8. Communication - in the Management of a FULL Patient Assignment

	1 - Limited Experience	2	3	4	5	6	7	8	9	10 - Completely Independent
Documentation/Charting of work	Documentation/Charting of work 1 - Limited Experience	Documentation/Charting of work 2	Documentation/Charting of work 3	Documentation/Charting of work 4	Documentation/Charting of work 5	Documentation/Charting of work 6	Documentation/Charting of work 7	Documentation/Charting of work 8	Documentation/Charting of work 9	Documentation/Charting of work 10 - Completely Independent
Computer skills	Computer skills 1 - Limited Experience	Computer skills 2	Computer skills 3	Computer skills 4	Computer skills 5	Computer skills 6	Computer skills 7	Computer skills 8	Computer skills 9	Computer skills 10 - Completely Independent
Hand-off communications - both given and received	Hand-off communications - both given and received 1 - Limited Experience	Hand-off communications - both given and received 2	Hand-off communications - both given and received 3	Hand-off communications - both given and received 4	Hand-off communications - both given and received 5	Hand-off communications - both given and received 6	Hand-off communications - both given and received 7	Hand-off communications - both given and received 8	Hand-off communications - both given and received 9	Hand-off communications - both given and received 10 - Completely Independent
Interactions with patients, colleagues, etc.	Interactions with patients, colleagues, etc. 1 - Limited Experience	Interactions with patients, colleagues, etc. 2	Interactions with patients, colleagues, etc. 3	Interactions with patients, colleagues, etc. 4	Interactions with patients, colleagues, etc. 5	Interactions with patients, colleagues, etc. 6	Interactions with patients, colleagues, etc. 7	Interactions with patients, colleagues, etc. 8	Interactions with patients, colleagues, etc. 9	Interactions with patients, colleagues, etc. 10 - Completely Independent

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* 9. Critical Thinking - in the Management of a FULL Patient Assignment

	1 - Limited Experience	2	3	4	5	6	7	8	9	10 - Completely Independent
Knows own limits; Seeks help when needed	Knows own limits; Seeks help when needed 1 - Limited Experience	Knows own limits; Seeks help when needed 2	Knows own limits; Seeks help when needed 3	Knows own limits; Seeks help when needed 4	Knows own limits; Seeks help when needed 5	Knows own limits; Seeks help when needed 6	Knows own limits; Seeks help when needed 7	Knows own limits; Seeks help when needed 8	Knows own limits; Seeks help when needed 9	Knows own limits; Seeks help when needed 10 - Completely Independent
Demonstrates self confidence	Demonstrates self confidence 1 - Limited Experience	Demonstrates self confidence 2	Demonstrates self confidence 3	Demonstrates self confidence 4	Demonstrates self confidence 5	Demonstrates self confidence 6	Demonstrates self confidence 7	Demonstrates self confidence 8	Demonstrates self confidence 9	Demonstrates self confidence 10 - Completely Independent
Recognizes changes in patient conditions or equipment	Recognizes changes in patient conditions or equipment 1 - Limited Experience	Recognizes changes in patient conditions or equipment 2	Recognizes changes in patient conditions or equipment 3	Recognizes changes in patient conditions or equipment 4	Recognizes changes in patient conditions or equipment 5	Recognizes changes in patient conditions or equipment 6	Recognizes changes in patient conditions or equipment 7	Recognizes changes in patient conditions or equipment 8	Recognizes changes in patient conditions or equipment 9	Recognizes changes in patient conditions or equipment 10 - Completely Independent
Evaluates situation and plans appropriate interventions	Evaluates situation and plans appropriate interventions 1 - Limited Experience	Evaluates situation and plans appropriate interventions 2	Evaluates situation and plans appropriate interventions 3	Evaluates situation and plans appropriate interventions 4	Evaluates situation and plans appropriate interventions 5	Evaluates situation and plans appropriate interventions 6	Evaluates situation and plans appropriate interventions 7	Evaluates situation and plans appropriate interventions 8	Evaluates situation and plans appropriate interventions 9	Evaluates situation and plans appropriate interventions 10 - Completely Independent

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* 10. Leadership and Management Skills - in the Management of a FULL Patient Assignment

	1 - Limited Experience	2	3	4	5	6	7	8	9	10 - Completely Independent
Demonstrates organizational skills	Demonstrates organizational skills 1 - Limited Experience	Demonstrates organizational skills 2	Demonstrates organizational skills 3	Demonstrates organizational skills 4	Demonstrates organizational skills 5	Demonstrates organizational skills 6	Demonstrates organizational skills 7	Demonstrates organizational skills 8	Demonstrates organizational skills 9	Demonstrates organizational skills 10 - Completely Independent
Sets priorities during work experience	Sets priorities during work experience 1 - Limited Experience	Sets priorities during work experience 2	Sets priorities during work experience 3	Sets priorities during work experience 4	Sets priorities during work experience 5	Sets priorities during work experience 6	Sets priorities during work experience 7	Sets priorities during work experience 8	Sets priorities during work experience 9	Sets priorities during work experience 10 - Completely Independent
Works toward independence	Works toward independence 1 - Limited Experience	Works toward independence 2	Works toward independence 3	Works toward independence 4	Works toward independence 5	Works toward independence 6	Works toward independence 7	Works toward independence 8	Works toward independence 9	Works toward independence 10 - Completely Independent
Delegates effectively	Delegates effectively 1 - Limited Experience	Delegates effectively 2	Delegates effectively 3	Delegates effectively 4	Delegates effectively 5	Delegates effectively 6	Delegates effectively 7	Delegates effectively 8	Delegates effectively 9	Delegates effectively 10 - Completely Independent
Demonstrates accountability as a team member	Demonstrates accountability as a team member 1 - Limited Experience	Demonstrates accountability as a team member 2	Demonstrates accountability as a team member 3	Demonstrates accountability as a team member 4	Demonstrates accountability as a team member 5	Demonstrates accountability as a team member 6	Demonstrates accountability as a team member 7	Demonstrates accountability as a team member 8	Demonstrates accountability as a team member 9	Demonstrates accountability as a team member 10 - Completely Independent
Utilizes resources appropriately	Utilizes resources appropriately 1 - Limited Experience	Utilizes resources appropriately 2	Utilizes resources appropriately 3	Utilizes resources appropriately 4	Utilizes resources appropriately 5	Utilizes resources appropriately 6	Utilizes resources appropriately 7	Utilizes resources appropriately 8	Utilizes resources appropriately 9	Utilizes resources appropriately 10 - Completely Independent

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* 11. Human Caring and Relationship Skills - in the Management of a FULL Patient Assignment

	1 - Limited Experience	2	3	4	5	6	7	8	9	10 - Completely Independent
Interactions with patients/families	Interactions with patients/families 1 - Limited Experience	Interactions with patients/families 2	Interactions with patients/families 3	Interactions with patients/families 4	Interactions with patients/families 5	Interactions with patients/families 6	Interactions with patients/families 7	Interactions with patients/families 8	Interactions with patients/families 9	Interactions with patients/families 10 - Completely Independent
Interactions with team members anf other health care providers	Interactions with team members anf other health care providers 1 - Limited Experience	Interactions with team members anf other health care providers 2	Interactions with team members anf other health care providers 3	Interactions with team members anf other health care providers 4	Interactions with team members anf other health care providers 5	Interactions with team members anf other health care providers 6	Interactions with team members anf other health care providers 7	Interactions with team members anf other health care providers 8	Interactions with team members anf other health care providers 9	Interactions with team members anf other health care providers 10 - Completely Independent
Age/culture appropriate care	Age/culture appropriate care 1 - Limited Experience	Age/culture appropriate care 2	Age/culture appropriate care 3	Age/culture appropriate care 4	Age/culture appropriate care 5	Age/culture appropriate care 6	Age/culture appropriate care 7	Age/culture appropriate care 8	Age/culture appropriate care 9	Age/culture appropriate care 10 - Completely Independent
Demonstrates customer service behaviors	Demonstrates customer service behaviors 1 - Limited Experience	Demonstrates customer service behaviors 2	Demonstrates customer service behaviors 3	Demonstrates customer service behaviors 4	Demonstrates customer service behaviors 5	Demonstrates customer service behaviors 6	Demonstrates customer service behaviors 7	Demonstrates customer service behaviors 8	Demonstrates customer service behaviors 9	Demonstrates customer service behaviors 10 - Completely Independent
Maintains confidentiality	Maintains confidentiality 1 - Limited Experience	Maintains confidentiality 2	Maintains confidentiality 3	Maintains confidentiality 4	Maintains confidentiality 5	Maintains confidentiality 6	Maintains confidentiality 7	Maintains confidentiality 8	Maintains confidentiality 9	Maintains confidentiality 10 - Completely Independent

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* 12. Teaching Skills - in the Management of a FULL Patient Assignment

	1 - Limited Experience	2	3	4	5	6	7	8	9	10 - Completely Independent
Participation in orientation/preceptor program	Participation in orientation/preceptor program 1 - Limited Experience	Participation in orientation/preceptor program 2	Participation in orientation/preceptor program 3	Participation in orientation/preceptor program 4	Participation in orientation/preceptor program 5	Participation in orientation/preceptor program 6	Participation in orientation/preceptor program 7	Participation in orientation/preceptor program 8	Participation in orientation/preceptor program 9	Participation in orientation/preceptor program 10 - Completely Independent
Initiates own learning opportunities	Initiates own learning opportunities 1 - Limited Experience	Initiates own learning opportunities 2	Initiates own learning opportunities 3	Initiates own learning opportunities 4	Initiates own learning opportunities 5	Initiates own learning opportunities 6	Initiates own learning opportunities 7	Initiates own learning opportunities 8	Initiates own learning opportunities 9	Initiates own learning opportunities 10 - Completely Independent
Completes patient teaching	Completes patient teaching 1 - Limited Experience	Completes patient teaching 2	Completes patient teaching 3	Completes patient teaching 4	Completes patient teaching 5	Completes patient teaching 6	Completes patient teaching 7	Completes patient teaching 8	Completes patient teaching 9	Completes patient teaching 10 - Completely Independent
Engages in professional development	Engages in professional development 1 - Limited Experience	Engages in professional development 2	Engages in professional development 3	Engages in professional development 4	Engages in professional development 5	Engages in professional development 6	Engages in professional development 7	Engages in professional development 8	Engages in professional development 9	Engages in professional development 10 - Completely Independent

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* 13. Knowledge Integration and Unit Specific Skills - in the Management of a FULL Patient Assignment

	1 - Limited Experience	2	3	4	5	6	7	8	9	10
Management of specialty specific clients	Management of specialty specific clients 1 - Limited Experience	Management of specialty specific clients 2	Management of specialty specific clients 3	Management of specialty specific clients 4	Management of specialty specific clients 5	Management of specialty specific clients 6	Management of specialty specific clients 7	Management of specialty specific clients 8	Management of specialty specific clients 9	Management of specialty specific clients 10
Personal role development within specialty	Personal role development within specialty 1 - Limited Experience	Personal role development within specialty 2	Personal role development within specialty 3	Personal role development within specialty 4	Personal role development within specialty 5	Personal role development within specialty 6	Personal role development within specialty 7	Personal role development within specialty 8	Personal role development within specialty 9	Personal role development within specialty 10
Specialty specific procedures and equipment	Specialty specific procedures and equipment 1 - Limited Experience	Specialty specific procedures and equipment 2	Specialty specific procedures and equipment 3	Specialty specific procedures and equipment 4	Specialty specific procedures and equipment 5	Specialty specific procedures and equipment 6	Specialty specific procedures and equipment 7	Specialty specific procedures and equipment 8	Specialty specific procedures and equipment 9	Specialty specific procedures and equipment 10
Completion of unit-specific skills	Completion of unit-specific skills 1 - Limited Experience	Completion of unit-specific skills 2	Completion of unit-specific skills 3	Completion of unit-specific skills 4	Completion of unit-specific skills 5	Completion of unit-specific skills 6	Completion of unit-specific skills 7	Completion of unit-specific skills 8	Completion of unit-specific skills 9	Completion of unit-specific skills 10
Adheres to protocols consistently while delivering care	Adheres to protocols consistently while delivering care 1 - Limited Experience	Adheres to protocols consistently while delivering care 2	Adheres to protocols consistently while delivering care 3	Adheres to protocols consistently while delivering care 4	Adheres to protocols consistently while delivering care 5	Adheres to protocols consistently while delivering care 6	Adheres to protocols consistently while delivering care 7	Adheres to protocols consistently while delivering care 8	Adheres to protocols consistently while delivering care 9	Adheres to protocols consistently while delivering care 10