College of DuPage
Medic to Practical Nursing
Clinical Evaluation Tool
 This tool is designed for evaluating a student’s clinical performance. It requires completion by
the nursing faculty with input from the nursing student.
 Clinical evaluations are required at mid-term (MT) and end of the course. Ratings of 2 or less at
the mid-term must have a plan for corrective action developed, and noted in the General
Comments section of the Tool.
 For final score, all clinical outcome criteria must be a rating of 2 or above in order to pass the
course and complete this certificate program.
 If the student is at any time determined to be unsafe the student will be removed from the
clinical and will be evaluated for removal from the program.
Rating scores:
4
Excellent
3
Above average
2
Average (meets
competency)
Below average
1
0
Fails to meet
standard
Consistently performs Clinical Outcome criteria proficiently,
accurately and safely.
Performs all Clinical Outcome criteria proficiently and safely with
few supportive cues needed for accuracy, with increasing
confidence.
Performs clinical outcome criteria with minimal supportive cues
needed for accuracy.
Requires frequent and ongoing supportive cues to perform
Clinical Outcome criteria.
Performs Clinical Outcome criteria in unsafe, unethical and/or
inaccurate manner.
1. Differentiate the role and legal scope of practice of the LPN from that of corpsman and other
healthcare team members.
Clinical Outcome Criteria
Demonstrates clinical practice appropriate for the role related to such
tasks as care planning, communication and delegation
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Medic to Practical Nursing: Clinical Evaluation Tool (2015-2016)
MT score
Final Score
2. Demonstrate the role and legal scope of practice of the LPN.
Related Board of Nursing Competency(s): 1, 2, 14
Clinical Outcome Criteria
Maintains patient confidentiality
Demonstrates accountability for nursing care
Functions as patient advocate
MT score
Final Score
3. Utilize the nursing process in collaboration with other healthcare team members and
patients/families to address health care needs of individuals/families across the life span and in
a variety of health care settings (Emphasis will be on care of the elderly and in long term care
facilities.)
Related Board of Nursing Competency(s): 3, 5, 6, 8, 10, 11
Clinical Outcome Criteria
Constructs the nursing care plan taking into account development, family,
and cultural influences.
Communicates with health care team members to plan comprehensive
care plan
Evaluates patient response to nursing interventions
Implements comprehensive care for patient at the end-of-life taking into
consideration advance directives and cultural implication.
Delivers safe and timely care to elderly patients with common conditions
and chronic illness.
Differentiates physical findings that may be due to normal changes on
aging.
MT score
Final Score
4. Provide safe, culturally sensitive care to patients while keeping within the scope of practice of the
LPN and utilizing the nursing process.
Related Board of Nursing Competency(s): 12, 13
Clinical Outcome Criteria
Performs a comprehensive cultural assessment
Demonstrates awareness of culture as it impacts patient’s experience of
health and illness
Provides non-judgmental compassionate nursing care to a diverse patient
population
Verifies patient identification using 2 identifiers
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Medic to Practical Nursing: Clinical Evaluation Tool (2015-2016)
MT score
Final Score
5. Perform skills commonly delegated to and within the scope of practice of the LPN including
collecting data and reporting patient responses relative to designated skills.
Related Board of Nursing Competency(s): 13
Clinical Outcome Criteria
Performs head to toe assessment
Collects appropriate data following nursing interventions
Reports appropriate information to instructor and other members of the
healthcare team in a timely manner.
MT score
Final Score
MT score
Final Score
6. Administer medications within the LPN scope of practice.
Related Board of Nursing Competency(s): 9
Clinical Outcome Criteria
Calculate appropriate dosage and verify dose range based on weight or
BSA for each medication administered.
Verbalizes actions, side effects and adverse effects of medications
being administered
Utilizes the 6 rights for safe medication administration
Correctly documents medication administration on MAR
7. Communicate with patients, families, and members of the interdisciplinary health care team
incorporating interpersonal and therapeutic communication skills.
Related Board of Nursing Competency(s): 4
Clinical Outcome Criteria
Demonstrates effective communication strategies amongst patients,
nurses, and interprofessional team members.
Chooses communication techniques that minimize the potential for
conflict amongst patients, nurses, and interprofessional team members.
Values different styles of communication used by patients, families, and
healthcare providers.
Advocates for patient and family/significant others during the death
process to promote a respectful, peaceful death.
Recognizes signs and symptoms of caregiver stress and implements
strategies, and in collaboration with the RN and other members of the
health care team to assist caregivers coping.
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Medic to Practical Nursing: Clinical Evaluation Tool (2015-2016)
MT score
Final Score
8. Manage information technology related to communicating and providing patient care.
Related Board of Nursing Competency(s): 7
Clinical Outcome Criteria
Uses electronic media sources to develop health promotion materials.
Uses EMR appropriately and effectively in Simulation and/or clinical
facility.
Writes electronic journal of activities in clinical practicum.
MT score
Final Score
9. Describe the purpose and significance of health promotion, identify factors for patients’ readiness
to learn and discuss/develop in collaboration with a RN, a teaching plan for patients of various
ages.
Clinical Outcome Criteria
Uses evidence-based teaching methods appropriate to patient/family level
of development and readiness.
Provides evidence-based teaching on primary prevention, health
promotion and restoration.
MT score
Final Score
10. Demonstrate understanding of the basis for nursing actions, considering research, evidence,
tradition and patient socio-cultural, ethnic and spiritual preferences.
Clinical Outcome Criteria
Provides evidenced-based rationales for nursing interventions based on
patient's developmental level in planning patient care.
Uses evidenced-based patient teaching methods appropriate to the
patient's level of development.
Implements evidenced-based interventions in providing care.
Provides evidence-based teaching on primary prevention/health and
safety promotion activities.
MT score
Final Score
11. Demonstrate professional accountability, competency, and compliance with legal and ethical
standards in LPN practice.
Related Board of Nursing Competency(s): 1
Clinical Outcome Criteria
Attends the clinical day, prepared, on time and in proper attire.
Willingly accepts and applies instructor feedback.
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Medic to Practical Nursing: Clinical Evaluation Tool (2015-2016)
MT score
Final Score
General Comments
Date
Comments/Behaviors observed
5
Corrective Action if applicable
Medic to Practical Nursing: Clinical Evaluation Tool (2015-2016)
Mid-term Review signatures and dates:
Student:
_____________________________________________________
Date:
______
Faculty:
_____________________________________________________
Date:
______
Final Review signatures and dates:
Student:
_____________________________________________________
Date:
______
Faculty:
_____________________________________________________
Date:
______
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Medic to Practical Nursing: Clinical Evaluation Tool (2015-2016)