St. John Fisher College Wegmans School of Nursing NURS 403 Mental Health Clinical Evaluation Tool

Transcription

1 Student: Semester/Year: Clinical Course: Agency/Unit: Date(s) of Absences: Mid-Term Clinical Evaluation: Satisfactory: At Risk: (See comment page) Clinical Faculty Signature: Student Signature: Date: Date: Final Clinical Evaluation: Satisfactory/Grade: Unsatisfactory/Grade: (See comment page) Clinical Faculty Signature: Student Signature: Date: Date: Behavioral Criteria Rating: Satisfactory = S Needs Improvement = NI Unsatisfactory = U No opportunity to meet Behavioral Criteria = NA In order to PASS the clinical component of the course, the student must demonstrate Satisfactory Clinical Performance by the Final Evaluation on ALL behavioral criteria in Bold Unsatisfactory Clinical Performance is receiving an NI or a U on ANY of the Behavioral Criteria in Bold by the Final Evaluation. An evaluation of Needs Improvement or Unsatisfactory on the final evaluation requires that the student must repeat the course in order to successfully progress to the next clinical course. 1

2 QSEN Core Competencies & Behavioral Criteria Midterm Final Midterm comments Final Comments Provides Patient-Centered Care (Program Outcomes #1, 2, 3, 5, 8) Identify opportunities for teaching health promotion, risk reduction and disease prevention and incorporate into the patient plan of care Use therapeutic communication in the nurse-patient relationship Identify barriers to communication with the patient with sensory deficits, language barriers and or psychosocial disabilities Integrate holistic care that is sensitive and compassionate into the care of patients and families Demonstrate sensitivity to personal and cultural influences on the individual s reactions to the illness experience and or end of life Apply ethical decision-making frameworks to analyze conflicts in clinical situations Advocate for clients and support their right to safe, compassionate and holistic nursing care Exhibits Teamwork and Collaboration (Program Outcomes # 3, 4, 7) Demonstrates professional collaboration with members of the health care team to improve patient outcomes Participate as a member of the interdisciplinary health care team Demonstrate an awareness of own strengths and limitations as a team member 2

3 Incorporates Evidence-Based Practice (Program Outcomes # 3, 7) Midterm Final Midterm comments Final Comments Integrate evidence-based knowledge from nursing and the sciences as the basis for practice Locate evidence reports related to clinical practice topics and outcomes Incorporates evidenced based information into patient teaching and or teaching plans Understands and Applies Quality Improvement Methods (Program Outcomes # 2, 6, 7) Demonstrates accountability and responsibility for own professional behavioral development Engage in self directed learning practices Aware and participates as possible in the units quality improvement plans Seek and contribute/participate in the units quality improvement plans Identify gaps between local/hospital and best practice Promotes Safety (Program Outcomes # 1, 3, 4, 7) Protect the safety and privacy of patients in relation to the use of health care and information technologies Provide safe patient care Demonstrate safe medication administration Report, document, and seek to remedy errors that have been made 3

4 Understands and Utilizes Informatics (Program Outcomes # 3, 7, 9) Midterm Final Midterm comments Final Comments Use information technologies to communicate health promotion/disease prevention information to the patient Thoroughly and accurately document interventions and nursing outcomes within unit timeframe Use appropriate technologies in the process of assessing and monitoring patients Personal Knowledge, Skill & Leadership Development (Program Outcomes # 1-9) Use knowledge of biopsychosocial and nursing science in the application of the nursing process Assess, manage and anticipate physical, psychological, social and spiritual symptoms/issues and or complications related to the disease process Produce clear and accurate written work and submit on time Use clinical judgment and decision making skills in the analysis and assessment of data and the planning of therapeutic interventions and evaluation of outcomes Demonstrate competence and independence in technical skills required to deliver nursing care at this level Apply the professional nursing code of ethics and standards of practice in practice Assume a leadership role within ones scope of practice Demonstrate initiative and self-direction to achieve goals Uses self evaluation, peer and faculty feedback to determine the effectiveness of one s practice and the need for change 4

5 Student Midterm Evaluation Summary: (to be completed by student prior to evaluation) Student Final Evaluation Summary: (to be completed by student prior to evaluation) Student Signature Date Faculty Midterm Evaluation Summary: Student Signature Date Faculty Final Evaluation Summary: Care experiences: Care experiences: Student Strengths: Student Strengths: Areas for Improvement: Areas for improvement: Faculty Signature Date Faculty Signature Date 5

6 St. John Fisher College Bachelors of Science Program Outcomes 1. Advocate for clients and support their right to safe, compassionate and holistic nursing care. 2. Integrate critical thinking and decision making throughout the nursing process to improve the care of clients. 3. Practice as a responsible member of the nursing profession reflecting current nursing standards of practice including ethical and legal accountability. 4. Apply basic organizational and systems leadership for quality care and patient safety in the provision and management of health care. 5. Practice patient-centered care respectfully and non-judgmentally with diverse populations of individuals, families and communities. 6. Engage in on-going, self directed learning, self-evaluation and goal setting throughout their nursing career. 7. Engage in the scholarship of evidence based practice and research to support high quality health outcomes and safe nursing care. 8. Promote clinical prevention and population health based on an understanding of global health issues. 9. Use information management systems and apply patient care technologies for clinical decision-making. 9/2011 6

7 Student: Faculty: PORTFOLIO ASSIGNMENT CHECKLIST Faculty: Date and initial when assignment is completed and scored. ASSIGNMENT DATE/INITIALS (And grade as appropriate) Due on SECOND simulation lab day: Self Awareness Tool Type written response to Self-Awareness Tool Student Information Sheet Due EVERY simulation/clinical day 1/16-4/13 Journal via submitted to clinical adjunct within 24 hours of clinical (to be filed in portfolio after clinical faculty provides feedback) Plan for completion of at least one assessment as outlined in Skills Checklist Completed during Clinical Rotation Post Conference patient presentation-15 One Article Evidence Based Practice-10 Due EVERY clinical of 1/30-4/13 Medication Card on Class Topic Drug Category for that week Present in Pre-Conference Due 3 rd clinical day: Ungraded Bio-psycho-social Assessment Due 4 th clinical day: Ungraded Process Recording Ungraded Priority Treatment Plan (Based on Bio-psycho-social Assessment) Due 5 th clinical day: Graded Bio-psycho-social Assessment Mid-term Evaluation summary portion (last page evaluation form)

8 Due 6 th clinical day: Graded Process recording Due 7 th clinical day: Graded Priority Treatment Plan (Based on Bio-psycho-social Assessment) Due 8 th clinical day: Completed Skills checklist 4 hour Community experience completed with submission of assigned write-up. (posted on BB) Due LAST clinical day: Self-Awareness Tool Discussion Questions Clinical Performance Evaluation Entire Portfolio AFTER ALL clinical days completed Evaluations to be scheduled on campus with clinical adjunct faculty no later than week of 4/16 Student to complete final evaluation summary portion and hand in completed Clinical Portfolio prior to meeting 8

9 Clinical Assessment Skills Checklist Skill Determine the Global Assessment of Functioning (GAF) score for a client. Document your rationale (GAF can be found in the DSM-IV, TR) Date/Initials Conduct an assessment for Tardive Dyskinesia using a standardized tool such as the AIMS. Conduct a paper and pencil screening for Depression. Document implications and interventions based upon the score.(refer to attached tools & your textbook for a selection of instruments) Conduct a paper and pencil screening for Anxiety. Document implications and interventions based upon the score.(refer to your textbook for a selection of instruments) Conduct a Brief Mental Status Exam Conduct a Lethality Assessment. Formulate interventions based upon findings (attached) Conduct a paper and pencil screening for Substance Abuse. Discuss findings and implications. Individual Crisis Prevention Plan (Violence/Aggression) 9