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Sonoma State University
Department of Nursing
Family Nurse Practitioner Program
Pediatric
Preceptor
Packet
N550ABC
MEW 3/15
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Department of Nursing
1801 East Cotati Avenue, Rohnert Park, California 94928-3609
707/664-2466
LETTER OF AGREEMENT
N550ABC
Letter of Agreements must be:
1.
Typed - LINK to FILLABLE Letter of Agreement:
http://sonoma.edu/nursing/resources/Letter of Agreement
fillable form.pdf
2.
Completed with address of site location, correct
dates and hours per week, and list specialty
(Family,OB/GYN, Peds or Other)
3. Signed by the Preceptor (PA’s need a Supervising MD Signature)
4. Accompanied with the preceptors’ CV
(you may submit a CV in lieu of the form below)
5. Sent to the Nursing Dept.: *****NOT POSTED IN MOODLE ****
Fax: (707) 664-2653
Email: nursing@sonoma.edu
Mail:
Sonoma State University
Nursing Dept.
1801 East Cotati Ave
Rohnert Park, CA 94928
Send 6 weeks before the semester begins.
It is ILLEGAL to start preceptorship without the above completed.
Please allow 2 weeks for processing. Incomplete forms will not be entered into Typhon.
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SONOMA STATE UNIVERSITY
Department of Nursing
FNP Preceptorship
Date:
If you prefer, you may submit a CV in lieu of this form, if the CV contains the information
contained in this form.
CLINICAL PRECEPTOR VITAE (BRIEF)
NAME:
PHONE NO.:
AGENCY:
Type of License:
License No.
Expires:
SCHOOL TRAINING INCLUDING COLLEGE OR UNIVERSITY & OTHER SCHOOLS IN
SPECIAL SUBJECTS:
Name of School
Location
Dates Attended
Degree or Diploma
Subjects Covered
Credit Equivalent
SPECIAL & PRIVATE TRAINING:
Name of Institution
Dates Attended
CLINICAL EXPERIENCE:
Type:
LENGTH OF EXPERIENCE:
4
MEMBERSHIPS IN PROFESSIONAL ORGANIZATIONS:
INTEREST AREAS IN WORKING WITH STUDENTS:
PREVIOUS EXPERIENCE PRECEPTING NP STUDENT: _______ NO _______ YES IF YES HOW
MANY STUDENTS? _________ ANY FROM SSU? ________
I certify that the information provided is accurate and complete to the best of my knowledge and
belief:
Signature:
Date:
PLEASE ATTACH A COPY OF YOUR LICENSE
NOTICE TO PRECEPTORS
Clinical adjunct professor status is available to our preceptors if desired. It is a courtesy title
without remuneration, and is designed to provide recognition of your valuable contribution to our
students and our program.
Should you desire such an appointment, please check here
following:
and complete the
SOCIAL SECURITY NUMBER:
EMERGENCY CONTACT INFORMATION
NAME:
STREET ADDRESS:
CITY:
PHONE:
STATE:
ZIP:
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Upon completion of the Pediatric preceptorship, the student will be able to:
A.
In physical diagnosis and nurse practitioner assessment process:
1.
Conduct a thorough intake history and physical exams
pertinent to the pediatric client.
Obtain appropriate interim history at routine well child visits.
Assess normal progression of growth and development using standard parameters,
i.e. height, weight, head circumference, BMI, Denver Developmental Milestones,
Bright Futures etc.
Order and interpret lab studies appropriately at various ages.
Evaluate immunization records and recommend necessary immunizations for age.
Assess psychosocial issues affecting child and/or related to parenting.
Assess for actual/potential chronic disease states such as Type I & II DM, HTN,
ADHD, Autism, developmental delay and obesity.
Routinely evaluate health care maintenance, activity, diet, school, at all visits
2.
3.
4.
5.
6.
7.
8.
B.
1.
2.
3.
4.
5.
6.
7.
C.
In management of health/illness conditions:
Provide patient education regarding normal physiological change of childhood,
growth and development, and diet and exercise in childhood.
Educate the patient regarding use of medication, computer/t.v./video games, and
illicit drugs.
Education related to age appropriate nutrition, safety concerns, developmental
issues
Explain lab tests or procedures being ordered. Manage
common complaints of childhood.
Consult and refer patients appropriately based on history and physical exam
finding/concerns.
Include psychosocial care and counseling as necessary.
Record accurately using problem oriented recording and/or forms when
appropriate (i.e. CHDP forms)
In role identity and professional development:
1.
2.
3.
4.
Interpret the role of the FNP to clients/parents and professionals.
Establish a professional relationship with preceptor, staff, and clients.
Present cases to preceptor in a clear, concise, and pertinent manner.
Accept responsibility for own learning.
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PEDIATRIC CLINICAL EVALUATION FORM
Student
Preceptor
Date:
Site
ASSESSMENT PROCESS (Age
appropriate assessment and age
appropriate interaction with child)
A
B
C
D
F
N/
A
A
B
C
D
F
N/
A
1. Gathers appropriate history
2. Uses good exam technique and is able to identity
normal vs. abnormal finding in the following
areas:
a. episodic exams
b. sports physical
c. well child exams
d. BP, Ht., Wt., HC, BMI (tracking percentile)
e. Growth and development
(Denver develop. Eval.)
3. Explores psychosocial concerns appropriately
4. Orders and interprets lab tests appropriate to
age and/or acute problems
5. Knows indications for special diagnostic tests,
spirometry, hearing, visual acuity
Comments:
MANAGEMENT OF HEALTH AND ILLNESS
1. Manages common complaints of childhood
2. Provides patient education re:
a. normal progression of growth and dev.,
school performance, school readiness
b. diet and exercise
c. soda, juice, caffeine, ETOH, tobacco, drug
use, T.V./ computer/internet use (screen
time)/phones
d. anticipatory guidance for child
and parent
e. safety specific to age and
activity
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f. can identify issue in
home/school: violence,
safety, satisfaction
g. immunizations
3. Identifies actual/potential risk of common
disorders seen in childhood
4. Provides counseling as needed
5. Plans for appropriate follow-up and/or referral
Comments:
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PEDIATRIC CLINICAL EVALUATION FORM
Page 2
1.
2.
3.
4.
ROLE IDENTITY AND PROFESSIONAL
RELATIONS
Interprets the FNP role to patients/parents
and other professionals
Presents cases to consultant in a clear,
well-organized manner
Develops effective relationships with preceptors,
staff and patients
Accepts responsibility for own learning
A
B
C
D
F
N/A
Comments:
If you would like to speak to someone directly related to this student’s performance please email the
director of the program at wilkosz@sonoma.edu (Dr. Mary Ellen Wilkosz) or call 707-664-2465 and
you will be directed to the appropriate clinical faculty member.
Preceptor signature
Date