Term                                            Clinical Make Up Session:   □ Pediatrics   □ Obstetrics                           

Student’s Name                                             Clinical Faculty                                                           __________________ Date:  ________________________

Clinical Site Hospital:                                                □                                           □                                             □ Other                             

Evaluate the student’s performance according to the following criteria:

S Satisfactory performance

U Unsatisfactory performance

  • Needs Improvement
  • Not observed

Comments: Document on any unsatisfactory areas or needs improvement, including prescription for improvement.

Date   Student     Faculty         CARING

1.  Provides humanistic, altruistic, compassionate, and empathetic client-centered caring interventions for the childbearing or  

    childrearing family safely and competently within the parameters of individual knowledge and experience.

  • Formulates and implements nursing care based on the social, developmental, spiritual, and cultural needs of the patient and family.
  • Integrates cultural values, beliefs, and practices into the planning and implementation of caring interventions.
  • Demonstrates sensitivity in caring for the needs of the childbearing or childrearing family.
  • Shows respect for human dignity and is nonjudgmental in patient and family interactions.


1.  Uses the nursing process to formulate, implement, evaluate and modify individualized plans of nursing care for the childbearing or

     childrearing family that demonstrates and incorporates critical thinking, evidence based practice, sound decision making, cultural  

     sensitivity, spirituality, developmental level, and uniqueness of each patient and family.

  • Provides nursing care to patients safely, accurately, and competently.
  • Recognizes the need for and implements, evaluates, and modifies teaching plans.
  • Uses principles of growth and development to apply the nursing process to patients of various ages.
  • Obtains necessary data from the patient’s record and through patient/family interview in planning and implementing care.
  • Promotes health of the patient by evaluating immunization and lab data.
  • Completes patient assessments according to hospital protocol.
  • Identifies deviations from normal and takes appropriate action in a timely manner.
  • Promotes age and developmentally appropriate self-care skills to patient and family.
  • Safely and accurately administers medications to patients and evaluates the therapeutic effects.

Date   Student     Faculty         COMMUNICATION

1.  Uses effective therapeutic communication skills when interacting and/or communicating with patients, families, and members of

     the health care team.

  • Demonstrates professional communication and behavior.
  • Documents accurately and completely all significant patient data according to agency protocol, using approved terminology and

    appropriate technology.

  • Is attentive when others speak.
  • Establishes therapeutic rapport with the patient and family.
  • Maintains clear, open communication with the health care team and instructor throughout the day.
  • Uses resources to communicate with patients and families from diverse populations.
  • Communicates learning and referral needs of families to the appropriate personnel.
  • Receives shift report from the registered nurse prior to providing patient care.
  • Gives complete ISBAR report to the registered nurse prior to leaving the unit.

Date   Student     Faculty         COMMITMENT TO PROFESSIONALISM

1.     Adheres to professional standards as defined by the Nurse Practice Act and Seminole State Student Policy Handbook.

  • Demonstrates professional responsibility and accountability in the role of the student learner.
  • Practices within the legal, ethical, and regulatory standards of professional nursing and the student nurse role while caring for the childbearing or childrearing family.
  • Arrives for clinical experiences on time, in uniform, and displaying a professional appearance.
  • Fulfills guidelines regarding preparation for clinical experiences.
  • Practices within the legal scope of the student learner.
  • Seeks opportunities to enhance learning in the clinical setting.
  • Shows respect for others.
  • Assumes responsibility for individual judgments and actions.
  • Acts in the role of patient advocate.
  • Maintains patient privacy and confidentiality.
  • Participates in clinically relevant discussions during post-conference, contributing acquired knowledge.

Date   Student     Faculty         COLLABORATION AND MANAGEMENT OF CARE

1.  Collaborates with patients, families and other health care professionals in planning and administering care to the childbearing or

     childrearing family.

  • Formulates individualized plan of care that demonstrates critical thinking, sound decision making, and independent judgment.
  • Selects priority nursing problems from assessment data.
  • Prioritizes between problems needing immediate attention from those requiring subsequent actions.
  • Develops goals and objectives that are realistic and support identified nursing problems.
  • Designs and implements individualized, goal-directed interventions for the patient’s priority problems.
  • Implements interventions that are goal-directed and meaningful.
  • Systematically evaluates the effectiveness of implemented strategies in meeting goal(s).
  • Identifies and/or develops alternatives to interventions that did not meet expected outcomes.
  • Follows up on interventions provided by other members of the healthcare team.

Student Signature:                                                                                                         Date:                                                         

Faculty Signature:                                                                                                         Date:                                                         

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