Formative Evaluation Tool
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1 LSUHSC School of Nursing Nurse Anesthesia Program Formative Evaluation Tool 1900 Gravier Street New Orleans, LA 70112 Program Director: L. Bonanno, CRNA, DNP (504) 568-4144 lbonan@lsuhsc.edu Student:____________________________________ Date:________________ Preceptor:_______________________________________________________ Site:____________________________________________________________ Semester #/Category_________________________ # of Cases_____________ Case:___________________________________________________________ ________________________________________________________________ Directions: Please indicate with an X the category that best describes the student’s performance today. Novice=N Needs constant guidance, relies on “rules”, disorganized, can’t focus-semester (Practicum 1 & 2) Advanced Beginner=AB Competent=C Needs help setting priorities, grasps basic flow of anesthetic, able to be left alone for short periods of time (Practicum 3) Organized, efficient, plans for problems, able to be left alone-semester (Practicum 4 & 5) Proficient=P Sees situation as a whole, requires minimal direction-semester (Practicum 6 & 7) Preoperative Evaluation & Preparation N AB C P N/A Performs an adequate preanesthetic patient interview & physical assessment Provides patients with explanations appropriate to age, educational & cultural levels Interprets preoperative diagnostic studies Selects or administers appropriate preoperative medication & treatments Selects and prepares indicated medications Correctly assembles & tests necessary equipment & monitors __ __ __ __ ___ __ __ __ __ ___ __ __ __ __ ___ __ __ __ __ ___ __ __ __ __ ___ __ __ __ __ __ __ Strengths:______________________________________________________ Areas for Improvement:________________________________________ ________________________________________________________________ _______________________________________________________________ _________________________________________________________________ _________________________________________________________________ Suggested methods for improvement :______________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ Anesthetic Management N AB C P N/A Formulates a patient & procedure –specific anesthetic care plan Provides correct rationale for management choices Manages induction of anesthesia Titrates anesthetic according to patient’s response Safely positions patient to maintain optimal function Interprets and evaluates monitoring data correctly Manages fluid and blood replacement Identifies and manages anticipated & unanticipated perioperative events Plans for and manages a controlled emergence Develops and institutes a plan for postoperative pain management Gives complete, concise report to PACU personnel __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Strengths:______________________________________________________ Areas for Improvement:______________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Suggested methods for improvement :_____________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 2 Technical Skills N AB C N/A Compliance with universal precautions Airway management w/ bag and mask Intubation technique Intraoperative ventilatory management Insertion of IV catheters Insertion of CVP/PA catheters Applies all needed monitors Placement of regional neural blockade Documents care accurately; completely, legibly Functions with minimal direction Work habits are organized and orderly Performs effectively in stressful situations __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Strengths:______________________________________________________ ________________________________________________________________ ________________________________________________________________ __ Areas for Improvement:_____________________________________ _______________________________________________________________ _______________________________________________________________ Suggested methods for improvement :_____________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ Professional Characteristics Satisfactory Collaborates with other members of anesthesia & surgical team Exhibits a responsive attitude to teaching & learning Recognizes limitations of knowledge & ability Accepts and adjusts to constructive criticism Written & verbal communication is effective and appropriate to level Demonstrates flexibility in new or changing situations as appropriate to level Performs effectively in stressful situations as appropriate to level Unsatisfactory __ __ __ __ __ __ __ __ __ __ __ __ __ __ Please rate the student’s overall performance: Novice □ Advanced Beginner □ Competent □ Proficient □ Preceptor’s Written Comments ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ Student’s Self-Evaluation ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ Preceptor: I discussed this evaluation with the student. ___________________________________________________________ Student: The preceptor discussed this evaluation with me__________________________________________________________ VSJ 7/08
