THIS FORM IS A PREVIEW ONLY!


MGH Institute of Health Professions
Graduate Program in Nursing
36 1st Ave.
Boston, MA. 02129

Advanced Practice Nursing Clinical Evaluation Tool

 (Question 1 of 28 )
Yes
No
Communication & Interrelations -Establishes rapport with patients, families, preceptor and all other providers and staff in the practice. Communication is patient-centered and appropriate. Maintains confidentiality

 (Question 2 of 28 )
Below Level 1
Level 1
Level 2
Level 3
Level 4
N/A
 
Needs much guidance for time management, or content of communication. 
Needs some guidance for time management, or content of communication.
Needs little guidance for time management, or content of communication.
Needs rare guidance for time management, or content of communication.
 
Time management and content of communication

 (Question 3 of 28 )
Yes
No
Cultural Humility - Demonstrates respect across cultures and willingness to learn with patients, families and health care team. Is responsive to diverse cultural health beliefs and practices, preferred languages, and health literacy.

 (Question 4 of 28 )
Below Level 1
Level 1
Level 2
Level 3
Level 4
N/A
 
Requires much guidance to include necessary data in an organized documentation format.
Requires some guidance to include necessary data in an organized documentation format. 
Requires little guidance to include necessary data in an organized documentation format. 
Requires rare guidance to include necessary data in an organized documentation format.
 
Documentation

 (Question 5 of 28 )
Yes
No
Subjective Assessment - Accurately collects Chief Complaint, Past Medical/Psychiatric History, Past Surgical History, Developmental History, Family History , Social History, Review of systems.

 (Question 6 of 28 )
Below Level 1
Level 1
Level 2
Level 3/4
N/A
Needs much guidance for chronology, pertinent positives and negatives in HPI for single complaint.
Needs some guidance for chronology, pertinent positives and negatives in HPI for single complaint.
Needs rare guidance for chronology, pertinent positives and negatives in HPI for single complaint.
 
History of Present Illness (HPI) for single complaint

 (Question 7 of 28 )
Below Level 1
Level 1
Level 2
Level 3
Level 4
N/A
 
Needs much guidance for chronology, pertinent positives and negatives in HPI for multiple complaints.
Needs some guidance for chronology, pertinent positives and negatives in HPI for multiple complaints.
Needs little guidance for chronology, pertinent positives and negatives in HPI for multiple complaints.
Needs rare guidance for chronology, pertinent positives and negatives in HPI for multiple complaints.
 
History of Present Illness (HPI) for multiple complaints

 (Question 8 of 28 )
Yes
No
Physical/Psychiatric Assessment - Performs organized age-appropriate systematic examination with minimal guidance.

 (Question 9 of 28 )
Below Level 1
Level 1
Level 2/3/4
N/A
 
Needs little guidance guidance with pertinent elements to include in complete exams.
Needs rare guidance in complete exams.
 
Complete Physical and/or Psychiatric Exams

 (Question 10 of 28 )
Below Level 1
Level 1
Level 2
Level 3
Level 4
N/A
 
Needs much guidance with pertinent elements to include in focused exams.
Needs some guidance with pertinent elements to include in focused exams.
Needs little guidance with pertinent elements to include in focused exams.
Needs rare guidance in focused exams.
 
Focused Physical and/or Psychiatric Exams

 (Question 11 of 28 )
Yes
No
Diagnostic Clinical Reasoning - Considers history, physical/psychiatric assessments, and diagnostic tests when making diagnostic decisions.

 (Question 12 of 28 )
Below Level 1
Level 1
Level 2
Level 3
Level 4
N/A
 
Needs much guidance to develop differential diagnoses for conditions common in this practice
Needs some guidance to develop differential diagnoses for conditions common in this practice
Needs little guidance to develop differential diagnoses for conditions common in this practice
Needs rare guidance to develop differential diagnoses for conditions common in this practice
 
Differential Dx for common conditions in this setting

 (Question 13 of 28 )
Below Level 1
Level 1/2/3
Level 4
N/A
 
 Needs much guidance to develop differential diagnoses for uncommon or complex conditions. Needs some guidance to develop differential diagnoses for uncommon or complex conditions.
 
Differential Dx for complex or conditions uncommon in this setting

 (Question 14 of 28 )
Yes
No
Plans for care - Uses references appropriately. Reviews all plans with preceptor.

 (Question 15 of 28 )
Below Level 1
Level 1
Level 2
Level 3/4
N/A
 
Needs some guidance with plans for conditions common in this setting.
Needs little guidance with plans for conditions common in this setting.
Needs rare guidance with plans for conditions common in this setting.
 
Makes plans of care for conditions commonly seen in the setting

 (Question 16 of 28 )
Below Level 1
Level 1
Level 2/3/4
N/A
 
 Needs much guidance with plans for conditions uncommon in this setting or unfamiliar to student. Needs some guidance with plans for conditions uncommon in this setting or unfamiliar to student.
 
Makes plans of care for conditions uncommonly seen in the setting, or unfamiliar to the student.

 (Question 17 of 28 )
Below Level 1
Level 1
Level 2
Level 3
Level 4
N/A
 
Uses resources and needs much guidance to determine most patient needs for screening, health promotion, and teaching.
Uses resources and needs some guidance to determine most patient needs for screening, health promotion, and teaching.
Uses resources and needs little guidance to determine most patient needs for screening, health promotion, and teaching.
Uses resources and needs rare guidance to determine most patient needs for screening, health promotion, and teaching.
 
Screening, health promotion, patient teaching

 (Question 18 of 28 )
Below Level 1
Level 1
Level 2
Level 3
Level 4
N/A


Uses record systems with much guidance.
Uses record systems with some guidance.
Uses record systems with minimal guidance.
Uses record systems with rare guidance.
 
Record System

 (Question 19 of 28 )
Below Level 1
Level 1
Level 2
Level 3/4
N/A
 
Beginning understanding of coverage, billing and coding.
Developing understanding of coverage, billing and coding.
Demonstrated understanding of coverage, billing and coding with little guidance.
 
Regulations, coverage, billing, coding

 (Question 20 of 28 )
Below Average
Fair
Good
Very Good
Exceptional
N/A
Professionalism: Punctuality, attendance, appearance, acceptance of feedback, flexibility, responsibility for time commitments, prompt communication, other specify below.

 (Question 21 of 28 )
If any of the above questions were answered with a "Below Level 1" rating, please explain.
 

 (Question 22 of 28 )
What are the strengths of this student?
 

 (Question 23 of 28 )
In what area(s) does the student need to improve?
 

 (Question 24 of 28 )
Yes
No
For Final Evaluation Only - Based on your interactions and observations, do you recommend that this student advance to the next clinical level?

 (Question 25 of 28 )
If No, please explain:
 

 (Question 26 of 28 )
What is the specialty or type of practice?
 

What population(s) is/are primarily served? (select all that apply)     (Question 27 of 28 )

Selection Option
Adult
Older Adult
Pediatric - Under 5 years
Pediatric - Over 5 years
Adolescent
Obstetric
Women's Health
Psychiatric
Acute Care (please specify below)
Underserved (please specify below)
Other

 (Question 28 of 28 )
Other important information about this practice:
 


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