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Clinical Instructor
Handbook
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Contents
1. Faculty Orientation Requirements
2. Faculty Orientation Verification Form*
3. Department Clinical Orientation Guidelines
4. Instructor Guidelines for a Successful Clinical
5. Out-Rotation Guidelines
6. Preceptorship Guidelines
7. Clinical Department Orientation Form*
8. Nursing and Clinical Student Policy
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Clinical Resources
 Sample Student Assignment Form
page
 Sample Clinical Assignment Form
page
 Badge/Car Registration Request Process & Form page
 CHL (Epic) Request form*
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* Denotes forms that must be turned in
Clinical Placement Website
http://www.conehealth.com/clinical-placement
All current information and forms related to clinical are posted here.
Contact Information:
Staff Education Department
staff.education@conehealth.com or 336.832.8173
Connie Lewter RN, MSN, CNE
Clinical Education Coordinator
connie.lewter@conehealth.com or 336.832.4363
Email contact for Department Leadership and anyone at Cone
Health: firstname.lastname@conehealth.com
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Faculty Orientation Requirements
Cone Health requires all newly hired clinical instructors, employees new to the faculty role, and
those who have had clinical teaching experience in Cone Health but have not been in the system
for a year or more to:
Access the Clinical Placement web site http://www.conehealth.com/healthcare-professionals/clinicalplacement to review and complete:
o New-Faculty Clinical Orientation Handbook
o Other important information found on the Clinical Placement Web Site
o Clinical Placement Request, Department Information, and the Clinical Placement
Schedule Grid
o Link to the NCAHEC website (Core Orientation) and the Cone Health Orientation
PowerPoint (required orientation for students and faculty initially and annually).
Orientation Acknowledgement Form, Department Orientation Form
* Attend Clinical Orientation for all new employees. Call Staff Education to register for orientation.
(336.832.8173). Parking is provided in the upper lot on Olive Street.
 All orientation is held in the Nursing Education Center (4th floor) at 200 E. Northwood,
Greensboro, NC.
o Tuesday – Clinical Orientation (8a-4p)
o Wednesday- Equipment day (8a-3p)
o Thursday- Cone HealthLink training (8a-4p)
 Training may be provided at the school
 Submit CHL Log-in request form to the Epic center
Schedule Department Orientation – Schedule 16 hours on the department where you will initially
have students.
 Cone Health Employee- As needed or 8 hours, if not department staff member
 After the initial department orientation, schedule 8 hours orientation if you go to a
different clinical site
o Faculty is to contact Department Leadership to arrange orientation.
See Clinical Placement website- ‘Clinical Department Information’ for contact info.
 Schedule Clinical Education Coordinator meeting
Faculty member to contact Clinical Education Coordinator (CEC) to arrange a meeting date/time connie.lewter@conehealth.com 336. 832.4363
o Prior to the scheduled CEC meeting- Review the Faculty Orientation Handbook and bring
it to the meeting, along with any questions you may have.
Special Note: * indicates Cone Health Employee Exemption.
Cone Health Employees are not permitted to use Employee ID (badge, computer log in), perform CBG
testing, or function as a staff member while in the instructor role. You will need to complete and submit
a request for a 2nd CHL log-in and a 2nd badge (request forms included)
For more information contact:
Connie Lewter, Clinical Education Coordinator connie.lewter@conehealth.com 336. 832.4363
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New Instructor Orientation Verification Form
Faculty Name: Print_____________________________ Sign: _______________________________
School:
Phone:
Email:
Your email address will be added to a Faculty Distribution List to receive periodic notifications.
As a new clinical faculty member joining our organization, we invite you to join us in our attempts to help you
transition into your new role. We look forward to partnering with you to provide exceptional clinical
experiences for students. Orientation to Cone Health is an integral part to your success as a clinical instructor.
Submission of this completed form is required prior to working with a clinical group at Cone Health.
For each item on the form you must have a signature validation.
Key- * indicates Cone Health Employee Exemption.
*Orientation:
Date: __________ (Tuesday 8a-4p)
Staff Educator _____________________________
Date: __________ (Wednesday 8a-1p)
Staff Educator _____________________________
Date: __________ (Thursday 8a-4p – CHL) Staff Educator _____________________________
Annual requirement - In addition to the New Faculty Orientation, verification of annual completion of the Core
Orientation and the Cone Health Orientation must be maintained at the school.
Clinical Education Coordinator Meeting: Date: _______
Form: Clinical Faculty Handbook _____
Access to Clinical Placement website ______
Department Orientation - 16 hrs or Cone Health Employee 8hrs. As needed if staff on the department.
Date: __________
# of hours ___
Staff Member:_____________________________
Date: __________
# of hours ___
Staff Member:____________________________
Date: _______
# of hours ____
Staff Member: _________________________
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Submit Badge Request form to Security Services & call 336.832.7849 to schedule appointment to pick up.
Submit the CHL log-in and training request form to the Epic Center.
Staff Educator II Clinical Education Coordinator: ____________________
Submission Date: _______
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Department Specific Clinical Orientation
Clinical Instructor department orientation is required prior to instructing on a new
department. Contact the department leadership to arrange this orientation. Instructors new
to Cone Health are required to have a 16 hour orientation. Experienced instructors need to
arrange an 8 hour orientation. Re-orientation of faculty with prior experience on the
department is determined between the instructor and the department leadership.
Shadow Experience: Staff preceptor
 Clinical faculty is paired with an Experienced Staff Member
 Spend time with clinical faculty
 Introduce faculty to staff members
 Share Unit information with faculty member
 Provide a unit orientation to faculty
 Allow faculty to work with preceptor on preceptor’s assignment
 Allow faculty to interact with various patients and families
Information Sharing
 Basic unit information
 Number of beds
 Staffing ratio (number of patient’s per nurse)
 Top 10 most common diagnoses
 Common meds
 Clinical Assignments
 How best to arrange for student assignments
 Pre-clinical
 Day of clinical
 Staff input
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 Posting student assignment for staff access
 Where to post
 Department format
 Information required- example:
 Patient Care Assignment
Faculty name
Student’s name
Room number/ patient’s initials
Start and End time
Student’s Clinical responsibilities
o Medication administration
o Patient care responsibilities, documentation etc.
 Basic Access Needs
 Pyxis Access
 Tutorial requirement, Pharmacy notification by Leadership
 Supply access
 location and codes
 Report design
 Initial report- walking rounds and how to accommodate for student report
 End-of-clinical Experience report to patient’s primary nurse
 Hands on demonstration of Bedside Equipment
 Monitors, vital sign equipment, special scales
 Common equipment (feeding pumps, lift equip etc.)
Discussion Time
 Meet and Discuss Factors that Hinder or Enhance the Learning Environment for
Students:
 Discuss staff expectations of students and of faculty
 Discuss course objectives for the clinical experience; guidelines for interacting
with students
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Faculty Guidelines to Successful Collaborative Clinical Experiences
Cone Health requires all newly hired clinical instructors, Cone Health employees new to the clinical
faculty role, and those who have been out of the health system a year or more to complete the Faculty
Orientation Program. Contact the Staff Education Department to coordinate the process 832-8173.
See the Clinical Placement web site for more information:
https://www.conehealth.com/healthcare-professionals/clinical-placement
Cone Health is committed to supporting our community and our school affiliates by
providing quality experiences for students and faculty. Some initiatives include:
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A culture that values collaboration with our affiliate partners to provide exceptional clinical experiences
Welcoming Orientations to incoming students
Pass Port clinical orientation process for students and faculty.
On-line Clinical Placement process
New-Faculty Orientation
Multiple clinical opportunities throughout the Cone Health system
Mosby’s Nursing Consultant resource on the Intranet
Frequent updates of new initiatives for clinical faculty
Faculty are invited to attend the annual Skills Fair and other continuing education classes
Faculty Commitment to Students
 Student Supervision and Teaching.
It is the primary responsibility of the instructor to teach, supervise, and engage students while on the
department. Staff is available to “help” the students; their primary responsibility is to patient care.
• Clinical day - No students are permitted on the department without instructor present.
 Verify annual Core and Cone Health Orientation has been completed
 Provide Department Orientation
• Ensure each student has on proper attire (School and Cone Health dress code policy) and has a
school photo ID on and visible while in clinical
• Have students sign and then give the signed Department Orientation Document to your school
Education Partner who will reconcile with the request for the department and submit to Staff
Education. Due the first week of clinical
 Provide private space for group meetings.
Faculty Commitment to Department Staff and Patients
 Maintaining open communication between faculty/student/and staff is imperative to patient safety and
fosters a collegial relationship. It en
ncourages a climate of collaboration and mentorship and adds to the
overall positive clinical experiences between student, faculty, and staff.
 Prior to the start of the clinical day, faculty must post a list of student patient-care responsibilities on
the department and inform the patient ’s primary nurse about these activities.
 At the beginning of the shift and throughout the day, faculty should encourage collaboration between
the student and patient ’s primary nurse related to patient expectations and how the student can assist
with patient care during the clinical experience.
 Absence from clinical: If,, for any reason, faculty finds it necessary to cancel a scheduled clinical day you
must notify the department staff of your decision. They look forward to having your student ’s and
appreciate knowing when they will not be coming on the assigned shift.
 Protect Privacy: Conferences are prohibited in public areas. Printed materials with patient identifiers are
not permitted off the department.
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Faculty Commitment to Department Leadership
Clinical Instructors responsible for clinical group rotations, out-rotations and preceptorships are required to
contact Department Leadership at least one week prior to the first clinical day. See Clinical Department
Information (posted on the Clinical Placement website) to find leadership phone contact information.
Provide department leadership with the following information by email:
 Type of Program, level of student
 Clinical Course Objectives and specifically what outcomes are expected from this clinical
experience
 Clinical Schedule – days scheduled on department, start/end date and any days
scheduled off the department.
 List of students – if a rotation, state when each student will be on the department
 Conference and Storage Space: Space for pre/post conference and student meetings is limited throughout the
system. Clinical faculty must arrange for a private meeting room for student pre/post conference or any group
meeting. This can be done at every campus. You may want to ask the Department Leadership for space on the
department, however, if there isn’t a room available on the department to accommodate your need please call
the following room reservation contacts. MC- Mark Whitted 832-8176, MC Heart and Vascular Room- Robin
Edwards 832-9999, WL- Krystal Williams 832-0140, WH- Contact Department Leadership, AP- Vickie Walker 9514355.
• No group-meeting should be conducted in public areas.
 Clinical Hours: Every effort must be made to begin the clinical day at the start of the “traditional” shift.
7A, 3P, 7P. Students should be available to participate in the reporting process. This eliminates the
need for a second report from the nurse, miscommunication, and contributes to an overall smoother
shift transition.
Faculty Commitment to Staff Education Department
 If documentation and medication administration will be a required part of the clinical experience,
please contact Staff.Education@conehealth.com for information about how to request training and
Cone Healthlink Access codes.
 Faculty who intend students to use Cone Health’s computer charting system/pass medications must arrange
training. Computer Access codes are required prior to the start of clinicals. Contact the NFC to arrange training
and access to Cone HealthLink.
 Submit the Clinical Orientation Agreement by the end of the first week of clinical
• This verifies that students have been oriented to the clinical department.
 Have students complete the Clinical Exit Survey, for each department they have clinical experiences in.
See Survey Monkey Link on the Clinical Placement Website.
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Cone Health Out-Rotations
All out-rotation requests are arranged through the Cone Health Staff
Education Department using the Group Clinical Request Form-set.
These requests are submitted exclusively through the School’s
Education Partner affiliated with Cone Health. Unless otherwise
agreed upon, direct contact with department leadership for clinical
placement is not made until approval has been obtained through
Staff Education.
Out-rotations are defined as 1 – 2 day specialty department clinical
experiences, previously arranged for students in a clinical group on
a Cone Health hospital campus. The purpose of the out-rotation is
to supplement the clinical group department experience. This is a
non-instructor led experience with the student shadowing or
providing direct patient care under the supervision of the
appropriate department staff as instructor guidelines permit. The
Instructor is responsible for contacting the department and
providing:
 Course syllabus
 Specific clinical objectives and guidelines for the out-rotation
clinical experience
 Schedule with students names and dates of rotations
 Instructor contact information
Instructors are to be on the same hospital campus as where the outrotation experience occurs unless previously approved, by the
department leadership, to be as a different campus at the time of the
clinical experience. Out-rotations are not to be scheduled
independent of a clinical group scheduled at Cone Health.
Out-rotation sites are listed on the Group Clinical Request form
posted on the Clinical Placement website.
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Request for Preceptor Guided Clinical Experiences
To be completed by the school Clinical Coordinator prior to the start of
the clinical experience:
1. Request placement by submitting the completed Preceptorship Request Form
located at http://www.conehealth.com/clinicalplacement to the Staff Education
email below.
2. Contact both the Preceptor and the Department Leadership to arrange orientation
for the preceptor, and to provide student information.
3. Dialog with to preceptor providing the following information and opportunities for
questions:
• Overview of the relationship responsibilities of preceptor, faculty, and student
• Goals and objectives for the clinical experience
• Specific preceptor responsibilities
• Method of clinical evaluation of student by preceptor and faculty
• Ongoing support to both the preceptor and the student
4. Ensure students meet the student requirements for clinical placement outlined in
the Clinical Education Agreement.
5. Inform the student about preceptorship requirements and direct them to the
Clinical Placement page.
a. Orientation
b. Training and log-in access to the electronic medical record system (Cone
Health employee students will need a student log-in and may require
additional CHL training depending on their clinical site.
c. Photo ID badge requirement
d. Car registration and parking decal
6. Inform the student to contact the preceptor before the start of the clinical
experience in order to collaborate and to negotiate schedules, etc.
• Students are not permitted to begin clinicals without having contacted the
preceptor as instructed. This encourages a climate of collaboration and
mentorship and adds to the overall positive clinical experiences between
student, faculty, and staff.
We look forward to a wonderful collaborative relationship with your
school.
 Please let us know if you have any suggestions, questions, or concerns.
 Contact Information
•
Staff Education Department: 336.832.8173
staff.education@conehealth.com
•
Connie Lewter RN, MSN, CNE 336.832.4363
connie.lewter@conehealth.com
With our partnership, we can provide exceptional clinical experiences for students,
faculty, staff, and most importantly our patients and families.
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Clinical Department Orientation Form
The Cone Health Clinical Orientation Agreement is to be used by clinical faculty orienting students to the Department. Not
all content can be covered in the formal orientation program. Each signature verifies that the student has received a Cone
Health orientation, documentation training as applicable, and a departmental clinical orientation. Clinical Orientation and
the attached Signature Agreement Form are required for each new clinical rotation.
Cone Health supports the following Standards of Behavior as a means to better serve our patients and community.
Affiliates of Cone Health such as volunteers, contract personnel, vendors, students and others should be aware of these
policies and agree to abide by these principles as evidenced by their signature below.
CONE HEALTH- As a mission-driven organization, we value:
Outstanding Service -We are committed to outstanding care, services and management.
Caring Spirit -We demonstrate respect and compassion for all individuals.
Innovative Climate -We are committed to creativity and individual initiative.
Integrity -We are an organization characterized by high ethics and integrity.
Financial Viability - We are committed to financial viability to ensure the future of our organization.
STANDARDS OF BEHAVIOR
-Maintain a professional appearance.
-Maintain a safe, clean and attractive environment.
-Anticipate the needs of customers and others.
-Hold each other accountable to the Standards of Behavior.
-Demonstrate a positive attitude to everyone.
-Communicate with compassion and courtesy.
-Maintain customer privacy and confidentiality.
CONFIDENTIALITY
As an affiliate of Cone Health, I understand and agree that I must hold confidential Cone Health information and all
medical and patient information in confidence. I am not allowed to access any confidential information, medical record or
computer system unless necessary to perform my job duties. I may not access or ask someone to obtain for me my
medical information or that of family/others, unless needed to perform my job duties. I may not discuss, review and/or
reveal in any way confidential information that I may have as a result of my affiliation with Cone Health unless to do so is
within my assigned job duties. It has been explained to me and I understand that I am fully accountable for my actions.
Further, I understand that violation of Cone Health policies regarding privacy and confidentiality or any other breach of
confidentiality will result in immediate disciplinary action, up to and including termination.
CORPORATE COMPLIANCE
It is the intent of Cone Health to maintain sound, ethical standards in all that we do. Policies and procedures in support of
these standards are placed throughout the organization. I understand that as an affiliate of Cone Health I am required to
support those standards. I understand that there is a Corporate Compliance Hotline if I have concerns after talking with
my supervisor, that the call may be anonymous, and that Cone Health has a policy of non-retaliation.
SAFETY/QUALITY CONCERNS
Cone Health, the Joint Commission and the North Carolina Division of Health Services Regulation (DHSR) are committed
to patient safety and quality care. If I have a concern regarding safety or quality, I should:
1. Notify my immediate supervisor or the Director in the area.
2. If appropriate, have the incident entered into the Safety Zone Portal.
3. If I have an ongoing concern after seeking the assistance of the Director and Vice President, I may discuss the matter
in a confidential manner by using Cone Health’s Compliance Hotline. The hotline number is 832-8888 or toll free 1-866506-8890.
4. If I continue to have concerns, I have the right to contact Joint Commission or DHSR @ ncdhhs.gov
Cone Health, Joint Commission and DHSR support a non-retaliation-reporting environment.
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Clinical Department Orientation Signature Page
By signing this document, I have completed the Student/Faculty Orientation and agree to abide by Cone Health
policies while associated with Cone Health and to seek assistance with and/or clarification of these policies if
needed. I have experienced a department specific orientation.
____________________
Hospital/Department
__________________
________
Semester
Date
______________________
School/Program
________________________ ____________________________
Print- Faculty Name
Faculty Signature
____________________
Clinical Day(s)
_________________________
Clinical Hours (example 7a-7p)
Student: Print first and last name
Student Signatures
This agreement must be completed and returned to your school Education Partner. The Education
Partner will reconcile the orientation documentation with the clinical placement request and submit to
the Staff Education Department before the end of the first quarter of the clinical rotation. Failure to
comply will result in the cancellation of your clinical assignment.
Connie Lewter, RN MSN, CNE
Staff Educator II Clinical Education Coordinator
Cone Health
Staff Education
1200 N. Elm St.
Greensboro, N.C. 27401-1020
Staff Education Staff.Education@conehealth.com
Phone #- 336-832-8173 and Fax #- 336-832-7175T
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CONE HEALTH
Policies and Procedures
Department Originating Policy:
Policy Code:
Nursing
ER-SED-2010-64
Department Specific Review
(Title):
Manager of Staff Education
Approval Council/Committee:
Nurse Executive Committee and Nursing
Leadership Council
Policy Title:
Next Required Reviewed/Revised
Date:
April 2015
Date Approved by
Council/Committee:
August 10, 2010
Archived Date:
Nursing and Clinical Students at Cone Health
PURPOSE:
Cone Health (CH) is dedicated to providing a safe health care environment for all patients, as well as a learning
environment for all students. Clinical students will have access to a wide array of educational opportunities
designed to facilitate the development of highly skilled and knowledgeable professional caregivers. In
partnership with educational institutions, students will practice under the direct supervision of faculty
instructors and/or Cone Health Registered Nurse (RN) preceptors, as well as other licensed practitioners. The
licensed professional, whether faculty instructor or Cone Health preceptor, will supervise all care provided by
the student in the clinical setting.
DEFINITIONS:
1. “Student” shall mean a student officially enrolled in the Program at an Educational Institution who
participates in a clinical experience at any of the Cone Health sites. Students shall include
undergraduate, graduate, and licensed professionals returning to the clinical setting for a
clinical/occupational experience as part of their educational program.
2. “Faculty” shall mean each individual employed by or affiliated with the Institution of Education to
instruct and supervise students as part of the Program.
3. “Preceptor” shall mean an individual who is an employee of Cone Health and facilitates student learning
and provides guidance and evaluation of students at CH as part of the Clinical/Occupational Experience.
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4. “Clinical/Occupational Experience” shall mean a structured learning experience at CH in which a
student provides care to patients under the guidance of a faculty instructor or Cone Health preceptor.
5. “Program” shall individually and collectively mean the program(s) in which student(s) is/are
enrolled at an educational Institution and receive all pre-clinical placement training and education
related to their field.
POLICY:
Overview
Nursing and clinical students may perform activities that are permitted within the scope of practice for the
level of education (RN or LPN, EMT) and school and clinical agency policy, provided licensed
faculty/preceptor or RN is supervising them. No student will be allowed to perform a procedure that requires
specialty training and/or certification for their practice discipline.
This Policy Applies to:
All Cone Health facilities and to all clinical students.
Dress Code for Students/Faculty:
1. Students must wear the designated school uniform or abide by the unit-specific attire (ex. scrubs,
business casual). Students/faculty must wear an authorized school photo ID while on duty and identify
themselves as a student/faculty at all times. Additionally, students and faculty must adhere to the Cone
Health policy for “Dress Code” (Human Resources Policy # II-ER-6).
2. Cone Health employees participating in clinical experiences as a student or faculty must identify
themselves as a student/faculty and wear an authorized school photo ID while in the student/faculty role.
They may not wear their Cone Health ID or use their employee logons while performing in their
student/faculty role.
Faculty Instructor\Student Orientation:
1. Cone Health requires all newly hired nursing faculty, employees new to the faculty role, and those who
have had clinical teaching experience in Cone Health, but have been away for a year or more, to attend
the General Nursing Orientation and complete Cone Health’s Faculty Orientation process.
2. Faculty instructors will complete unit-based orientation prior to supervising students on the unit.
Faculty will contact the director of the department PRIOR to the clinical experience to arrange this
orientation.
3. Faculty must contact the unit director to share course and clinical objectives, to give them the student list
and scheduled dates and times of clinical, as well as faculty contact information, PRIOR to beginning
the clinical experience. Failure to submit the contact information, objectives, student list, dates of
clinical etc. will result in the clinical group not being allowed on the unit. The instructor will be
responsible for notifying the Department Director when schedule changes affect the presence or absence
of students in the clinical area.
4. Each semester, and as changes occur, the educational institution is required to submit a roster of all
faculty instructors supervising students in clinical rotations no later than the first day of the clinical
experience. This list should be sent electronically to the Cone Health Staff Education Mail Box:
staff.education@conehealth.com
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5. Faculty instructors are responsible for orienting students prior to their arrival on the unit according to the
Cone Health Student and Faculty Orientation Process. This information is current on the Cone Health
Clinical Placement website.
6. Annually, faculty and students must complete the on-line Core Orientation process and the Cone Health
Orientation process found on the Cone Health Clinical Placement Website.
Supervision of Students:
1. Student supervision is the responsibility of the faculty instructor or Cone Health preceptor.
2. Faculty instructors must be present in the facility at all times and be available by phone or pager.
Exception: For precepted or graduate students, a faculty instructor must be available by phone or pager
while the student is within the Cone Health S system.
3. Ultimate responsibility for patient care rests with the patient’s Cone Health primary caregiver. At any
time the Cone Health primary caregiver deems necessary, he/she can assume care of any patient
assigned to a student.
Computer Use by Students:
1. All clinical students doing documentation of patient care must complete the Cone HealthLink computer
training class. Upon successful completion of the documentation training exercise the student will be
given a computer access code.
2. No student will use a Cone Health staff member or faculty’s access code to enter the electronic
documentation system or any other electronic data base.
Documentation/Charting by Students:
1. Students may document in the patient’s medical record with the supervision of the faculty instructor or
Cone Health preceptor.
2. Students must comply with all Cone Health system documentation policies.
Medications:
1. Students administering medications must be under the direct supervision of a Registered Nurse. It is
required that nursing students be observed either by their clinical faculty, by the RN assigned to the
students, or by the RN preceptors in the preparation, administration and documentation of insulin,
anticoagulants and all IV push medications.
2. Students will not be issued passwords for the automated medication dispensing system. Medications
must be obtained through the faculty instructor or Cone Health preceptor.
3. Administering and charting medications will be according to the Cone Health Policy, “Medication
Administration and Bar Code Scanning”
4. Students may not administer investigational drugs or any drugs that require specialized training to
administer (e.g. chemotherapeutic drugs, vaso-active drugs, and Intravenous conscious sedation).
5. Students are not permitted to conduct narcotic counts.
REVIEWED/REVISED DATES:
April.2012
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Department Assignment Communication Form
School: _________________________
Program: _______________________________
Instructor: __________________________ Contact telephone # ___________________
Date: ______________
Time: _________________
Student
Staff Nurse
Document
Document
Document
Document
Last Name
and
Pt. Room #
Name
and
Wireless #
Vital Signs
am/pm
Bath/Linen
chg./Activity
/ADL etc.
I&O
( Hourly IV
fluids/and all
I&O)
Assessments
&
Flow-sheets
(circle)
8
12
4
8
12
4
8
12
4
8
12
4
8
12
4
8
12
4
8
12
4
8
12
4
1. Were students on time for report? Yes/ No
2. Was staff Nurse notified in a timely manner if above plan for day changed? Yes/No
3. Was the Nursing Instructor visible, available, and accountable for the students? Yes/No
4. Did Staff Nurses receive report before students left? Yes/No
5. Did Nursing Instructor check with Staff Nurse before she/he left for the day? Yes/No
Conference Time: ________
Medication/
Document
Medication
Document
Medication
Document
All oral, IV,
NG/GT,
topical etc.
Oral Only
IV Only
Medicatio
n
Document
NG/GT
Only
Scheduled
Procedures
Dressings,
wound care
Etc.
6. Staff Nurse Evaluation: Was plan completed? Place an X in the area that was not completed
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Faculty Name __________________________
Name/Age
Physician
Diagnosis
Vital Signs
Clinical Worksheet
Diet/Activity
I&O
IV
Date_____________
Medications
Lab/
Diagnostics
Miscellaneous
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CONE HEALTH BADGE PROCESS
Cone Health Security requires all students and clinical instructors to wear a Cone Health badge
when at a Cone Health site. In addition to the badges signifying the student or clinical instructor is
someone authorized to be on the premises, the badges will increasingly be needed for entry access.
REQUEST for Nursing class or groups of students
For each new group of students, the school Education Partner will submit:
1. A Cone Health Badge request form to Security.Services@Conehealth.com .The
Request Form is posted on the Clinical Placement webpage. Be sure to use the
Student tab for students and the Faculty tab for faculty who need a badge.
2. A document containing an individual JPEG formatted photo of each student. Title
each JPEG file with the student’s name/school ID #.
 Ensure correct spelling to avoid a fee for remaking a badge.
 To allow sufficient time, the Cone Health Badge request form should be sent one
month prior to the first clinical at Cone Health. The JPEG photo document can be
sent later, if need be at two weeks prior to the initial clinical.
PICK UP
3. You will be notified when the badges are ready for pick up from the MC Security
Department. Badges will be issued by Moses Cone Hospital Security, regardless of
which hospital campus the students are attending. One school representative is
asked to pick up the badges for the school program for dispersing to the students.
The MC Security Department, Office: 336-832-7849, email
secserv1@conehealth.com is located on the ground floor, straight back from the
service elevators.
REQUEST for Individual Students or Faculty
The Clinical Coordinator will submit the Badge Request form and direct the
student to contact Security Services at 336-832-7849 or email
secserv1@conehealth.com to schedule an appointment to have the badge made.
Appointments can usually be scheduled in a few days, takes 10 – 15 minutes and
the badge will be ready for use.
REPLACEMENT BADGES The initial badges will be provided without cost, but replacement badges
will incur a fee. There will be a charge for the next student badges if the current badges are not
returned.
RETURN


The badges will be programed to expire on the graduation date.
The school is responsible for collecting and returning the badges. If a student leaves the
program for any reason or no longer has a need for the badge prior to graduation, then
the school is asked to immediately notify Security Services and return the badge. A fee
will be charged to the school for badges that are not returned.
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Cone Health Badge/Parking Form Instructions
For Students and Instructors
Once a preceptorship has been confirmed or a new instructor has been verified, the school
Education Partner will be given a signed Badge Request form to be completed and submitted by the
student following these instructions.
1. Submit the Badge/Parking request form directly to secserv1@conehealth.com after
the request has been approved.
2. Call Security Services at 336.832.7849 to schedule an appointment to
have a photo made if needed and to pick up your badge. (Not available on
Mondays)
The Badge/Parking Request form is not modifiable, so below is a guide of information to provide
on the form to better reflect what is needed for students and instructors rather than employees:

EID# - type in School ID Number

Department - type in the specific Hospital(s) or Ambulatory Care site.

Job Title - type in School and Program name, Student/Instructor Name.

Reason for new badge - Select Other
o Student - type in: ‘Student / Beginning date of clinical is ______. Ending date
of Clinical is _______.’
o Instructor – type in: ‘Instructor on-going’
Parking for students at the Moses Cone Hospital campus is on the 3 rd level of the Visitor’s deck which
is accessed from Church Street. For parking at other locations, ask your preceptor for guidance.
The Badge must be returned at the end of your clinical work for the school to not be
charged for the next student badge.
Badge/Parking forms are posted on the Clinical Placement webpage:
http://www.conehealth.com/clinicalplacement
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Badge ID Request and Parking Registration Form
(Please Print Legibly)
First
M.I.
Last
EID #/SAN
Preferred Name (name you prefer to be called):
Department:
Job Title:
Credentials/Degrees (maximum of 3):
Campus at which you work:
MC
Phone # (work):
WL
AP
WH
BHH
ARMC
Homecare
Daycare
Other:
Reason(s) for new badge:
If badge has been lost or damaged due to neglect of the employee, a fee will be charged. A $10 fee should be paid at the Cashier’s
Office on your campus or at General Accounting (MC Campus Room #0640) and a copy of the receipt submitted with this form.
Old badge must be turned in to Security Services at time of accepting new badge.
Vehicle Information
Color
Year
Make
Model
Tag #
State
Decal #
(Office Use)
This form is located on Cone Connects in the Human Resources Folder.
Completed form may be submitted to Security Services: 1) Delivered by hand to any security office, 2) emailed to
secserv1@conehealth.com or fax to 336-832-2993. After submitting the form, call 336.832.7849 to schedule
appointment to have the photo made and pick up the badge.
Form will not be accepted if not completed and signed by Department Director, Manager or Supervisor.
Connie Lewter, Clinical Education Coordinator
Department Director, Manager or Supervisor - Signature
Connie Lewter (2)4363
Date
21
Clinical Student Training/Access Request Form
Please email completed form to keya.shah@conehealth.com or fax to 336-832-9060.
Student Name: _____________________ _____________________ ______________________
First
Middle
Last
Approval of a preceptor ship is required prior to submission of this form. If approval has not already been
obtained, you must first contact Staff Education at 336-832-8173 before submitting this form.
*Please note - All fields are required in order to grant access.
School Name:
___________________________________________________
Program Name:
___________________________________________________
Instructor’s Name:
___________________________________________________
Start Date for rotation/preceptor ship _______________________________________________
Graduation Date:
___________________________________________________
Clinical Site(s) you will be visiting:
___________________________________________________
Last 4 of Student ID:
___________________________________________________
Month/Day of Student’s Birthday:
___________________________________________________
Email Address:
___________________________________________________
Contact Number:
___________________________________________________
Cone Health Employee ID Number:
___________________________________________________
(If current Cone Health employee)
State the Cone Health employee, contact information and department who has approved your preceptor
ship.
Name:
_________________________________________ Phone # _______________________
Department: _________________________________________
Will you be providing direct patient care:
Yes
No
Please contact 336-832-9000 between 8:00am-12:00pm Monday-Friday for questions.
Training/access requests must be received at least 4 weeks in advance of requested clinical start date.
22
Cone Health would like to
thank you for your partnership
with us in providing
exceptional care for our patients
and exceptional learning experiences
for your students.
LLaasstt u
uppddaattee 1100..22..1144