Midterm Final US S E NA Applies principles of epidemiology and demography in clinical practice.

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1 Indiana University-Purdue University Fort Wayne College of Health and Human Services Department of Nursing Clinical Evaluation Form: Nurse Practitioner Graduate Program Student Name: Preceptor Name: Semester Evaluation by: self preceptor Course being evaluated: Women s Health Practicum I Women s Health Practicum II Synthesis and Application Acute Illness Preceptorship Chronic Illness Preceptorship Role of the NP in Practice Management Concepts and Applications Health Promotion in Special Populations Midterm Evaluation Key: US = Unsatisfactory S = Satisfactory E = Excellent Evaluation key: 0 Omitted required item (omitted a critical element) 1 Required extensive prompting 2 Required much prompting 3 Required moderate prompting 4 Required minimal prompting 5 Performed independently NA Not available Satisfactory Performance: To be considered satisfactory at the completion of the clinical practicum, a student must earn a score of three (3) or higher in each domain. A score below three (3) in any domain is considered unsatisfactory and will result in practicum failure. Place an X in the box that best corresponds with the student s clinical performance for each Domain Competency. Domain I: Management of Patient Health /Illness Status Competencies: The nurse practitioner student demonstrates competence in the management of patient health/illness status as listed in Midterm 1. Provides health promotion services 2. Provides disease prevention services 3. Provides health protection interventions 4. Provides anticipatory guidance. 5. Provides counseling. 6. Promotes health environments. 7. Incorporates community needs, strengths, and resources into practice.

2 8. Applies principles of epidemiology and demography in clinical practice. Midterm 9. Demonstrates critical thinking and diagnostic reasoning in clinical decision making. 10. Obtains an accurate and complete health history. 11. Performs a physical examination. 12. Differentiates between normal, variations of normal and abnormal findings. 13. Employs screening and diagnostic strategies. 14. Analyzes data to determine health status. 15. Develops differential diagnosis. 16. Formulates a diagnosis. 17. Prioritizes health needs/problems. 18. Formulates and evidence-based action plan. 19. Initiates therapeutic interventions 20. Manages the health/illness status over time 21. Prescribes medications within legal authorization 22. Counsels the patient on the use of complementary/alternative/non-pharmacologic therapies 23. Evaluates outcomes of 24. Communicates effectively using professional terminology, format and technology 25. Provides for continuity of Domain II: The Nurse Practitioner-Patient Relationship demonstrates competence in the nurse/patient relationship as listed in 26-35: Midterm The preceptor may place an X in the boxes next to each 26. Attends to the patient s responses to changes in health status and 27. Creates a climate of mutual trust 28. Provides comfort and emotional support 29. Applies principles for behavioral change

3 30. Preserves the patient s control over decision making 31. Negotiates a mutually acceptable plan of 32. Maintains confidentiality and privacy 33. Respects the patient s inherent worth and dignity 34. Uses self-reflection to further a therapeutic relationship 35. Maintains professional boundaries Midterm Domain III: Teaching-Coaching Function demonstrates competence in the teachingcoaching function as listed in Midterm The preceptor may place an X in the boxes next to each 36. Assesses the patient s educational needs 37. Creates an effective learning environment 38. Designs a personalized plan for learning 39. Provides health education 40. Coaches the patient for behavioral changes 41. evaluates the outcomes of patient education Domain IV: Professional Role demonstrates competence in the professional role as listed in 42-57: Midterm 42. Demonstrates evidence-based approaches to 43. Delivers safe according to National Safety Guidelines 44. Functions in a variety of roles

4 45. Communicates personal strengths and professional limits 46. Advocates for the role of the advanced practice nurse 47. Markets the nurse practitioner role 48. Participates as a member of health teams 49. Collaborates with other health providers 50. Consults with other health providers 51. Advocates for the patient 52. Acts ethically 53. Incorporates current technology 54. Evaluates implications of health policy 55. Participates in policy making activities 56. Provides leadership 57. Accepts personal responsibility for professional development Midterm Domain V: Managing and Negotiating Health Care Delivery Systems demonstrates competence in managing and negotiating health delivery systems as listed in 58-66: Midterm 58. Incorporates access, cost, efficacy and quality when making decisions 59. Demonstrates current knowledge of health system financing as it affects delivery of 60. Analyzes organizational structure, functions, and resources to affect delivery of 61. Practices within an authorized scope of practice 62. Applies business strategies 63. Evaluates the impact of the health delivery system on 64. Participates in applicable community

5 health programs 65. Advocates for policies that positively affect health 66. Negotiates legislative change to influence health delivery systems Midterm Domain VI: Monitoring and Ensuring the Quality of Health Care Practices Competencies: The nurse practitioner student demonstrates competence in monitoring and ensuring the quality of health Midterm practice as listed in 67-69: 67. Monitors quality of 68. Assumes accountability of practice 69. Engages in continuous quality improvement Domain VII: Culturally-Sensitive Care demonstrates competence in culturallysensitive as listed in 70-75: Midterm 70. Prevents personal biases from interfering with the delivery of quality 71. Provides culturally sensitive 72. Assists patients of diverse cultures to access quality 73. Incorporates cultural preferences, values, health beliefs and behaviors into the management plan 74. Assists patients and families to meet their spiritual needs 75. Incorporates patient s spiritual beliefs into

6 Summary Comments by Preceptor: Preceptor Signature Date Summary Comments by Student (include goals for future professional development): Student Signature Date Summary Comments by Instructor: Instructor Signature Date Revised 8/27/2010