Preceptor Clinical Student Feedback Form

The preceptor clinical feedback from is designed for the preceptor to give feedback to the clinical faculty and the student on the student’s performance in clinicals. The student, over the course of the program, is expected to progress from the basic skills level in their first clinical course to intermediate or possibly high skills level during practicum. The form provides feedback and is intended to generate discussion and future performance goals with the clinical faculty. The clinical faculty will use the feedback from this form or verbally from the preceptor to evaluate the student and assign a final pass/fail grade. The clinical faculty evaluation form mimics the preceptor feedback form and has all of the same components.

Rating

Skill Level

Definition

1

Poor

Significant gaps exist in gathering patient information, interpretation of findings, and in the ability to generate even simple plans.  Consistently requires substantial assistance/supervision to perform task adequately and is not demonstrating growth towards independence.  Skill techniques are commonly incorrect. Communication is inaccurate and/or unclear. Does not demonstrate the ability to apply didactic content to the clinical setting. Does not understand practice parameters and/or there are concerns for unsafe practice. 

2

Novice

There is a good attempt but gaps exist in gathering patient information, interpretation of findings and in the ability to generate a plan.  A significant amount of assistance/supervision is needed, but student is moving toward independence. Skills demonstrate technique that is mostly correct but tentative and may need some correction. Communication is accurate but requires a lot of prompting form the preceptor and is disjointed or missing information.  Beginning to incorporate didactic knowledge and has little clinical experience from which to build or may know didactic content but has not had the opportunity to apply.

3

Competent

Performs clinical duties with skill and able to gather patient information, interpret findings and generate a simple plan accurately most of the time. Requires some assistance/supervision. Skills demonstrate correct technique but may be slow or uneven.  Communication is accurate but is disjointed or not succinct. Demonstrates ability to incorporate didactic knowledge and previous clinical experience

4

Proficient

Performs clinical duties with proficiency and skill. Gathers patient information, interprets data, and generates a plan with consistently accurate judgment. Needs minimal assistance/supervision. Psychomotor skills are smooth and sure. Communication is accurate, clear and succinct. Demonstrates clear ability to build on didactic knowledge and previous clinical experience.

0

Not Observed

There was not an opportunity to observe or verbally challenge the student with this competency. If > 4 competencies are not observed, the evaluator must assess the site and make a plan in conjunction with the student to meet all competencies.

Date of Evaluation  
//  
Mid-term / Final  
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
1. Critically analyzes data and evidence
2. Discusses pathophysiology and course of diseases
3. Applies psychosocial concepts related to health and illness
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
a. Obtains and accurately documents problem focused/ comprehensive age appropriate health histories
b. Includes a complete or focused evaluation of the ROS is appropriate
c. Modifies interview technique to meet differences in age, gender, and cultural factors
d. Includes pertinent developmental assessment across the lifespan
e. Performs risk assessment as appropriate
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
a. Performs episodic or complete physical examination accurately as appropriate
b. Performs physical exam techniques that are supported by subjective data
c. Displays consideration to safety, infection control, and cultural factors during the exam
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
6. Distinguishes between normal and abnormal
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
a. Formulates a list of differential diagnoses
b. Formulates accurate problem list supported by patient data
c. Produces and accurate list of client health risk behaviors and environmental health risks
d. Demonstrates ability to identify “red flags” requiring urgent or emergent care, consultation or referral
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
8. Includes appropriate follow-up/referral/consultation in the plan of care
9. Selects age and condition specific diagnostic tests and screening procedures
10. Identifies and plans appropriate health promotion education, counselling, and anticipatory guidance to the patient/family/caregiver
11. Identifies appropriate interventions (pharmacological & non-pharmacological)
12. Synthesizes data from a variety of sources including evidence-based practice recommendations to approach patient management
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
13. Integrates ethical principles in decision making and protects patient confidentiality
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
14. Translates technical and scientific information appropriately for patients
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
15. Maintains a climate of mutual respect and shared values
16. Communicates practice knowledge orally and in writing
17. Consistently and effectively participates in and/or leads an inter-professional team in the provision of care.
 1 Poor2 Novice3 Competent4 Proficient0 Not Observed
18. Demonstrates an understanding of the interdependence of policy and practice
19. Discusses ways to minimize risk of adverse patient outcomes
20. Evaluates access, cost, care processes and heath care structure when developing a management plan
NURS 787 - 73 points or above is passing
NURS 788 - 88 points or above is passing
NURS 789 - 102 Points or above is passing