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NURS-142 Clinical Progress Record

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0% found this document useful (0 votes)
97 views10 pages

NURS-142 Clinical Progress Record

Uploaded by

judlyhearty0
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Student Name: Judly-hearty Agyingi Student ID: 0686912

HOWARD COMMUNITY COLLEGE


NURSE EDUCATION PROGRAM
NURS-142 FUNDAMENTAL NURSING CONCEPTS
CLINICAL PROGRESS RECORD AND EVALUATION TOOL

Students will be evaluated on their clinical performance every week by their clinical instructors according to the grading descriptions below. The
clinical instructor will also keep track of student attendance, as the nursing program requires adherence to 135 clinical hours. Students will receive a
midterm and final grade based on established criteria identified as “Clinical Behaviors.” Students must Pass 19-25 clinical behaviors in the final
evaluation in order to pass clinical, and therefore NURS 142.

Week Week Week Week Week Week Week Week Week Week Week Week Week Week
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Attendance:
P= Present
P A P
L= Late
A= Absent
Clinical Grade:
P, NI, or F
N/A
(see below)

The student who is absent twice will fail clinical, and therefore NURS 142. Leaving clinical early for any reason counts as an absence. Arriving 30
minutes late to clinical for any reason counts as an absence. Simulation, skills evaluation and supervised practice counts towards clinical hours.
For students receiving a clinical grade of NI or F for the week, the clinical instructor is required to write a comment in the weekly progress record
with the reason and a plan for improvement.
P= Meets Expectations Clinical performance which consistently demonstrates safe and adequate application of the clinical behaviors within a
defined time frame with minimal verbal or nonverbal cues or assistance in integrating knowledge and skills.

NI= Needs Improvement Clinical performance which is inconsistent in application of clinical behaviors within a defined time frame; functions safely
and adequately only with moderate assistance, verbal or nonverbal cues, integrating knowledge with skills in the clinical
area.

F= Below Expectations Clinical performance which demonstrates unsafe or inadequate application of the clinical behaviors within a defined time
frame; requires frequent verbal or nonverbal cues or assistance to function on the clinical area, demonstrates gaps in
necessary knowledge or critical thinking and requires frequent or almost constant assistance in integrating knowledge and
skills.
Student Name: Judly-hearty Agyingi Student ID: 0686912
The nursing program expects students to exhibit professional behaviors at all times. Students failing to meet any of the Critical Professional
Behaviors below will earn a Critical Unsatisfactory (Critical U). Faculty will indicate the date when a student failed to meet a Critical Professional
Behavior. Documentation of the reason for the assignment of a critical U is to be written under faculty comments for the particular Clinical Behavior.
Students will acknowledge they received the Critical U by placing their initials in the table next to the faculty’s initials.

Critical Professional Behaviors Date(s) Faculty Initials Student Initials


1. Punctual to clinical, simulation, and scheduled laboratory experiences (including evaluation).
2. Punctual to pre and post-conference.
3. Notification of clinical faculty and agency 30 minutes prior to clinical start time if absent.
4. Prepared for clinical, simulation, and scheduled laboratory experiences (including evaluation).
5. Submits required assignments on time.
6. Assumes accountability for own actions.
7. Assumes responsibility for learning.
8. Assumes accountability for all assigned aspects of nursing care for their patient(s).
9. Adheres to required dress code.

The student earning 6 critical unsatisfactory behaviors will fail clinical, and therefore NURS 142.

I,Judly-hearty Agyingi, understand that if I am absent to clinical 2 times OR if I earn 6 critical unsatisfactory behaviors, I will fail clinical, and
therefore NURS 142.

Signature: Judly-hearty Agyingi Date: 09/12/2024

Criteria for passing clinical:


Midterm: Passing requires a Pass in 19-25 clinical behaviors. The evaluator is expected to comment on ALL items rated: NI or F. Comments must
include a plan for improvement for each clinical behaviors evaluated with a Fail (F) or Needs Improvement (NI). A Remediation Plan will be written
at midterm if the student is failing and, at the discretion of the clinical instructor, may be written for a student who needs improvement.

Final: Students must Pass 19-25 clinical behaviors in order to pass clinical, and therefore NURS 142.
Student Name: Judly-hearty Agyingi Student ID: 0686912
This Clinical Progress Record is to be completed and submitted to the clinical instructor weekly. The clinical instructor will return the Clinical
Progress Record with the attendance, clinical grade, and faculty comment if an NI or F was given. It is the responsibility of the student to regularly
review clinical instructor feedback and to meet with faculty to discuss plans to improve clinical performance.

Week 1: Date: 09/07/2024


Skills Practiced: Hand Washing, BP reading, PPE, Pulse
Orientation
What I did well: The hand washing was the easiest task to do and the PPE was easy as well.
On-Campus
What I need to improve on: I need to improve on using the stethoscope because when using it, I do not hear anything.
Skills
Improvement Plan: I plan on taking BP readings of my parents and family consistently and also attending the open labs on
campus.
Faculty Comment:
Week 2: Date: 09/08/2024
Skills Practiced: I was not present
On-Campus
What I did well: I was not present
Skills
What I need to improve on: Head to toe assessment
Improvement Plan: I will attend HCC open lab sessions from 8 AM- 2:30 PM and re-watch Mrs. Sabina Choi head to toe
assessment video.
Faculty Comment:
Week 3: Date: 09/14/2024
Patient Description: Today we did a group head to toe assessment on another assessing each component in the Head to toe.
Clinical Site
We were familiarizing ourselves with Epic and the department unit. We discussed input output system.
Nursing care/Interventions: We talked about the bladder scan, easily finding normal saline, consensus in PERRLA. We were
also advised by the nurse leader to be more empathetic with patients.
What I did well: I understood perfectly epic; I was able to know by whereabouts in clinic. The most pertinent questions I had
from missing last week lab were answered. I learned about the TAP system.
What I need to improve on: Doing the respiratory section in head-to-toe assessment and familiarizing myself with medicine.
Improvement Plan: I plan to review the medication sheet provided and learn their side effects; performing head-to- toe
assessment on family members.
Faculty Comment:
Week 4: Date: 09/21/2024
Patient Description: T.D-M is a 30yrs old African American Female who is fit. She is 68 kg and is approximately 157.5 cm tall.
Clinical Site
Nursing care/Interventions: Patient is taking Colace, Sennokot, Miralax for constipation. She is to an orthopedic doctor post
her surgery on 09/19/2024. In the meanwhile, she is taking Tylenol 1000 mg, Oxycodone for pain.
What I did well: When it pertains to maneuvering EPIC to obtain information, I believe I did good in that. Rapidly finding the
treatment for patients was something I did good on as well. I did well in communicating and connecting with patients.
Student Name: Judly-hearty Agyingi Student ID: 0686912
What I need to improve on: I need to improve on remembering to knock before entering patient’s room. I need to improve
on the resistance portion of my assessment. Also, I need to improve on self-protection by wearing gloves during head to toe
assessment.
Improvement Plan: Practice is key, and I plan on practicing with family members fake scenario. Also I will try to relax myself
before entering into the patient’s room so that out of nervousness I do not make an error.
Faculty Comment:
Week 5: Date:
Patient Description:
Clinical Site
Nursing care/Interventions:
What I did well:
What I need to improve on:
Improvement Plan:
Faculty Comment:
Week 6: Date:
Skills Practiced:
On-Campus
What I did well:
Skills
What I need to improve on:
Improvement Plan:
Faculty Comment:
Week 7: Date:
Skills Practiced:
On-Campus
What I did well:
Skills
What I need to improve on:
Improvement Plan:
Faculty Comment:
Week 8: Date:
Patient Description:
Clinical Site
Nursing care/Interventions:
What I did well:
What I need to improve on:
Improvement Plan:
Faculty Comment:
Midterm Comment (Required for Needs
Clinical Behaviors P NI F NO
Improvement and Fail)
Evaluation: Communication: Therapeutic and Interprofessional
Student Name: Judly-hearty Agyingi Student ID: 0686912
Elicits patient/family values, preferences and
expressed needs
Communicates effectively with patient and
significant other(s) (verbal, non-verbal, teaching)
Communicates effectively with the
intra/interprofessional team
Documents clearly, concisely, and accurately
Assessment
Obtains accurate, pertinent data based on client
needs
Performs follow-up assessments as needed
Assesses the environment for factors that may
impact the patient’s health status
Utilizes technology (electronic health record,
health databases) to obtain essential information
needed to plan safe and effective nursing care
Clinical Judgment and Evidence-Based Practice
Interprets assessment data correctly
Interprets diagnostic data correctly
Differentiates relevant from irrelevant data to
determine clinical problem
Researches the clinical problem to plan evidence-
based care
Prioritizes appropriately
Evaluates client response to medications and/or
therapies
Responds to abnormal findings appropriately
Implementation of Safe Nursing Practices
Uses two patient identifiers
Utilizes standard and transmission-based
precautions including hand hygiene for all
patients
Administers medications safely
Manages technology and equipment
Performs nursing procedures correctly
Student Name: Judly-hearty Agyingi Student ID: 0686912
Professionalism, Teamwork and Collaboration
Assumes accountability for the nursing care of the
assigned client(s)
Assumes accountability for own actions
Critiques own clinical performance
Functions within own scope of practice as a
member of the healthcare team
Interacts professionally with clients, significant
others, faculty, peers, and interprofessional team
Total: Circle One:
Pass: 19-25 P
Needs Improvement: 10-18 P
Fail: 0-9 P
Remediation Plan for Needs Improvement or Fail:

Clinical instructor notified the course coordinator:


Referral to lab was made:

Student Signature: Date:

Faculty Signature: Date:

Week 9: Date:
Patient Description:
Clinical Site
Nursing care/Interventions:
What I did well:
What I need to improve on:
Improvement Plan:
Faculty Comment:
Student Name: Judly-hearty Agyingi Student ID: 0686912
Week 10: Date: Patient Description:
Clinical Site
Nursing care/Interventions:
What I did well:
What I need to improve on:
Improvement Plan:
Faculty Comment:
Week 11: Date: Role:
Clinical Site
What I did well:
What I need to improve on:
Improvement Plan:
Faculty Comment:
Week 12: Date: What I did well:
Skills Evaluation
What I need to improve on:
Improvement Plan:
Faculty Comment:
Week 13: Date: Patient Description:
Clinical Site
Nursing care/Interventions:
What I did well:
What I need to improve on:
Improvement Plan:
Faculty Comment:
Thanksgiving Break
Week 14: Date:
Patient Description:
Clinical Site
Nursing care/Interventions:
What I did well:
What I need to improve on:
Improvement Plan:
Faculty Comment:
Student Name: Judly-hearty Agyingi Student ID: 0686912
Final Clinical Behaviors P F NO Comment (Required for Fail)
Evaluation: Communication: Therapeutic and Interprofessional
Elicits patient/family values, preferences and expressed
needs
Communicates effectively with patient and significant
other(s) (verbal, non-verbal, teaching)
Communicates effectively with the intra/interprofessional
team
Documents clearly, concisely, and accurately
Assessment
Obtains accurate, pertinent data based on client needs
Performs follow-up assessments as needed
Assesses the environment for factors that may impact the
patient’s health status
Utilizes technology (electronic health record, health
databases) to obtain essential information needed to plan
safe and effective nursing care
Clinical Judgment and Evidence-Based Practice
Interprets assessment data correctly
Interprets diagnostic data correctly
Differentiates relevant from irrelevant data to determine
clinical problem
Researches the clinical problem to plan evidence-based
care
Prioritizes appropriately
Evaluates client response to medications and/or therapies
Responds to abnormal findings appropriately
Implementation of Safe Nursing Practices
Uses two patient identifiers
Utilizes standard and transmission-based precautions
including hand hygiene for all patients
Administers medications safely
Manages technology and equipment
Student Name: Judly-hearty Agyingi Student ID: 0686912
Performs nursing procedures correctly
Professionalism, Teamwork and Collaboration
Assumes accountability for the nursing care of the
assigned client(s)
Assumes accountability for own actions
Critiques own clinical performance
Functions within own scope of practice as a member of
the healthcare team
Interacts professionally with clients, significant others,
faculty, peers, and interprofessional team
Total: Circle One:
Pass: 19-25 P
Fail: 0-18 P
Clinical Agency:

Number of absences (include dates):

Number of critical performance indicators (include dates):

Final Score:

Clinical Summary (faculty comments):

Student’s Comments: (optional)

This student passed the clinical component of NURS 142:


This student passed the NURS 142 Skills Evaluation:

Student Signature: Date:


Student Name: Judly-hearty Agyingi Student ID: 0686912
Faculty Signature: Date:

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