NOTE: Please complete and attach Staff Level Core Competencies with this evaluation tool.
Employee Name:
Evaluation Period:
to
LICENSED PRACTICAL NURSE (LPN) ANNUAL EVALUATION TOOL
Payroll Title: T & R Center LPN
Department: Nursing
Descriptive Title: Licensed Practical Nurse (LPN)
Salary Grade: SG010
Reports to: Nursing Manager or Assistant Manager (Inpatient
Date Reviewed: 9/29/2015
and Procedural Areas)
Patient Services Manager or Patient Services Supervisor
(Ambulatory Areas)
General Summary:
Under the direction of the Registered Nurse, the Licensed Practical Nurse performs as a bedside care provider. The LPN is responsible
for providing nursing care to patients/families and the community, observing, and reporting patient responses to treatment, overseeing
the work of ancillary staff and students assigned to the unit. The Licensed Practical Nurse exemplifies the Upstate mission, vision, and
values and acts in accordance with Upstate policies and procedures.
Validation Method:
Rating:
D=Demonstration
V=Verbalization
S=Simulation
DNM=Does Not Meet
O=Other (please specify)
M=Meets
E=Exceeds
Validation
Duties and Responsibilities:
Expectations
Method
DNM
M
E
Observation/Outcome
Reporting:
Collects comprehensive data
pertinent to the patient’s health
and/or situation and analyzes
data to determine plan of care
and set individualized outcomes.
Observes and reports patient status upon entry and
throughout hospitalization.
Collects/Observes and reports data that integrates
patient’s diagnoses, physical/psychosocial findings,
patient/family perceptions of illness, learning needs and
culture.
Identifies implications of patient status that vary from
normal.
Prioritizes care and data collection based on the patient’s
immediate condition.
Provides care based on population specific data based
on knowledge of growth and development.
Documents observations in a clear, concise, legible, and
accurate manner.
Comments:
Duties and Responsibilities:
Planning/Implementation/
Coordination/Evaluation:
Plans and implements the
delivery of nursing care for
patients in coordination with
the healthcare team.
Expectations
Cares for patient/family utilizing established
individualized plan of care that address age specific,
physical, psychosocial, cultural and educational needs.
Reports patient responses to care and interventions
including and changes in status.
Responds appropriately in emergencies by summoning
help, obtaining equipment, initiating CPR and/ or
attending to patients and unit needs as directed.
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Validation
Method
DNM
M
E
Duties and Responsibilities:
(Cont.)
Planning/Implementation/
Coordination/Evaluation:
Plans and implements the
delivery of nursing care for
patients in coordination with
the healthcare team.
Expectations
Consistently collaborates and communicates with
members of the health care team about patients.
Integrates care with other team members. Participates in
multi-disciplinary rounds.
Utilizes evidenced based interventions, treatments and
appropriate interdisciplinary resources to meet complex
patient/family needs.
Reports and documents care and progress toward
attainment of individualized outcomes.
Delivers safe care in a timely and efficient manner in
accordance with established policies and procedures.
Provides instruction to meet patient/family needs
utilizing appropriate instructional material. Documents
the provisions of information to patient/family in a clear,
concise, legible, and accurate manner.
Assists in providing basic patient care such as
ambulation, range of motion, support of activity,
hydration, nourishment, personal hygiene, comfort
measures, vital signs and toileting.
Transports patients in a courteous and safe manner.
Delivers patient care in accordance with unit specific
and Nursing Services policies and procedures.
Under the direction of the registered nurse, obtain
peripherally drawn blood specimen, obtain and transmits
12 lead EKG.
Under the direction of the registered nurse, may obtain,
document, and notify registered nurse of blood glucose
results obtained via point of care testing. May perform
glucometer quality control checks as per policy.
Delivers/obtains specimens, supplies and equipment as
needed. Notifies appropriate person.
Adjusts work routines to meet changing unit and patient
conditions.
Completes all components of assignment in order of
priority and seeks appropriate direction and assistance as
needed.
Validation
Method
DNM
M
E
Validation
Method
DNM
M
E
Comments:
Duties and Responsibilities:
Serves as a patient safety
companion.
Expectations
Completion of mandatory Patient Safety Training and
annual education.
Continuously facing the patient; will provide continuous
visual patient observation for patients at risk or on
suicide watch.
Receives verbal report, Kardex, and observation record
report from assigned RN or during unit report process.
Communicates observations related to patient behaviors,
affect, interactions with others and responses to safety
interventions to RN.
Documents observations of patient activity and
outcomes of interactions at least once per hour.
In collaboration with RN, offers diversional activities to
the patient.
Is alert and aware of all patient activity and avoids any
distractions.
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Duties and Responsibilities:
(cont.)
Serves as a patient safety
companion.
Expectations
Limits interactions with all other staff members in order
to focus on the patient and the patient’s behavior.
Maintains proximity to patient as determined by RN.
Validation
Method
DNM
M
E
Validation
Method
DNM
M
E
Validation
Method
DNM
M
E
Validation
Method
DNM
M
E
Adheres to all other requirements as outlined in UH
Administrative Policy CM S-13 for Safety Companions.
Comments:
Duties and Responsibilities:
Integrates ethics into actions.
Expectations
Preserves/protects patient autonomy, dignity, and rights.
Maintains patient confidentiality.
Comments:
Quality:
Enhances the quality and
effectiveness of nursing.
Identifies and participates in unit quality improvement
activities. Participates in data collection of unit based
research activities and modifies practice based
accordingly based on results.
Practices in a manner consistent with regulatory
standards and hospital policy.
Comments:
Duties and Responsibilities:
Communication/Collaboration/
Collegiality: Contributes to
teamwork. Carries out the
components of performance
necessary for successful Upstate
employees.
Expectations
Delegates appropriate tasks to ancillary workers.
Identifies potential conflict situations and facilitates
resolution.
Participates in the formation, implementation and
evaluation of unit goals.
Assists other members of the healthcare team in
completing their assignments.
Interacts with and contributes to the professional
development of others. Serves as a resource to new staff,
students and other Upstate personnel, this may include
acting as a formal preceptor.
Initiates requests for assistance when situations warrant
it.
Reports to work on time as scheduled and maintains an
acceptable record of attendance.
Attends and participates in staff meetings and submits
items for agendas as needed.
Comments:
Duties and Responsibilities:
Resource
Utilization/Environmental
Health:
Utilizes resources to provide
safe, effective and financially
responsible care.
Comments:
Expectations
Participates in creating environments that promote
health and healing, including attention to sound, noise
and light.
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Duties and Responsibilities:
Leadership:
Demonstrates leadership in the
practice setting.
Expectations
Directs/coordinates care, oversees care provided by
unlicensed nursing staff while retaining accountability
for quality of care provided to patients.
Serves as a preceptor to LPN students and unlicensed
nursing personnel.
Participates on committees/teams/councils.
Validation
Method
DNM
M
E
Validation
Method
DNM
M
E
Comments:
Duties and Responsibilities:
Takes and active role in
professional development.
Expectations
Identifies and communicates learning needs to
Nurse/Clinical Manager.
Pursues educational opportunities such as in
service/continuing education programs as appropriate.
Shares information from current literature and programs
attended. Incorporates new skills and knowledge into
practice.
Comments:
Minimum Qualifications:
 LPN Licensure and registration as outlined by NYS Education Department.
 Meets NYS Civil Service requirements.
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