UNIVERSITY OF PITTSBURGH SCHOOL OF NURSING
NURSE ANESTHESIA PROGRAM
R o t a t i o n S um m a r y E v a l ua t i on o f Cl i ni c a l P e r f or m a nc e
Student Name:
Rotation Dates:
Cardiac
Thoracic
Level / Eval Form:
Year 1: 4-6 mo
Mgt Plans in Compliance with
Site &/or Program Requirement?
Clinical Site: Select Site If Other:
Specialty:
2015 Fall
Neuro
Trauma
Pediatric
OB
Dental
Regional
Yes
Pain
No
Community
Assessment of Clinical Performance Relative to Level Objectives:
Comment is REQUIRED if rating is Unsatisfactory
Organization / Preparation:.......
Superior
|
Satisfactory
|
Unsatisfactory
Superior
|
Satisfactory
|
Unsatisfactory
Superior
|
Satisfactory
|
Unsatisfactory
Superior
|
Satisfactory
|
Unsatisfactory
Superior
|
Satisfactory
|
Unsatisfactory
Comments:
Clinical Knowledge Base: .........
Comments:
Technical Skills: ........................
Comments:
Management of Anesthetics: ...
Comments:
Professionalism / Motivation: ..
Comments:
Additional info if desired:
Student Comments: (use back if necessary)
Unable to meet with student – sent to Program Office.
Coordinator/Evaluator Signature
Student Signature
PRINT NAME:
Reviewed with Student
Date
Date
To be completed by Nurse Anesthesia Program:
Received: (date) ___________________
Faculty Review: ___________________________
Summary Evaluation and all daily evaluation materials and management plans should be returned
to the School office within 2 weeks of the end of the rotation.