Sonoma State University
Department of Nursing
Family Nurse Practitioner Program
OB Preceptor Packet
N550ABC
Rev 1/16 MEW
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.
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:
MEMBERSHIPS IN PROFESSIONAL ORGANIZATIONS:
INTEREST AREAS IN WORKING WITH STUDENTS:
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:
Upon completion of OB preceptorship, the student will be able to:
A.
In physical diagnosis and nurse practitioner assessment process:
1.
2.
3.
4.
5.
6.
7.
8.
B.
Conduct a thorough intake history and physical exams
pertinent to the new prenatal client.
Obtain appropriate interim history at routine prenatal visits.
Assess normal progression of pregnancy using standard parameters, i.e. urine
dipstick, BP, fundal height measurements, fetal heart tones, fetal movements,
etc.
Order and interpret lab studies appropriately at various stages of pregnancy.
Perform pelvic exams when necessary, including cultures/wet mounts, using
proper technique.
Assess psychosocial issues affecting pregnancy, birth and parenting.
Assess for actual/potential complications of pregnancy.
At post-partum visit, gather pertinent data related to labor and delivery,
problems/concerns, general adaptation and adjustment to parenting.
In management of health/illness conditions:
Provide patient education regarding normal physiological change of pregnancy,
fetal growth and development, and diet and exercise in pregnancy.
Educate the patient regarding use of caffeine, alcohol, tobacco, medications or
illicit drugs during pregnancy and breastfeeding.]
Explain lab tests or procedures being ordered.
Manage common complaints of pregnancy.
Educate patients regarding danger signs appropriate to gestational age and/or
puerperium.
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.
C.
In role identity and professional development:
1.
2.
3.
4.
Interpret the role of the FNP to clients 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.
OB CLINICAL EVALUATION FORM
Student
Preceptor
Date:
Site
ASSESSMENT PROCESS
A
B
C
D
E
N/
A
A
B
C
D
E
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.
b.
c.
d.
e.
pelvic exam
McDonald’s measurements
Fetal heart tone
BP, urine dipstick, edema
Begins to perform Leopold’s
maneuvers correctly
3. Explores psychosocial concerns appropriately
4. Orders and interprets lab tests appropriate to
gestational age and/or acute problems
5. Knows indications for special diagnostic tests, i.e.
U/S, NST, etc.
Comments:
MANAGEMENT OF HEALTH AND ILLNESS
1. Manages common complaints of pregnancy
2. Provides patient education re:
a. normal progression of pregnancy
b. diet and exercise
c. caffeine, ETOH, tobacco, drug use
d. preparation for labor, delivery,
and parenting
3. Identifies actual/potential risk of complication
to pregnancy
4. Provides counseling as needed
5. Plans for appropriate follow-up and/or referral
Comments:
OB CLINICAL EVALUATION FORM
Page 2
1.
2.
3.
4.
ROLE IDENTITY AND PROFESSIONAL
RELATIONS
Interprets the FNP role to patients 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
Comments:
Preceptor signature
Date
A
B
C
D
E
N/A