Sample Form

Registered Nurse Performance Appraisal

Appraisal Score

Overall Score:

/ 5.0

Employee Information
Name:

Division:

Job Title:

Department:

Evaluation Date:

Review Period
Review Period:

From:

Evaluated by:

To:

Job Description
Incumbent in this class performs process duties related to providing public health nursing care to
patients in a variety of community and clinical settings. Responsibilities include taking patient
histories, performing triage, providing assessments, and administering medications.

Instructions
At the beginning of the Hospitals fiscal year, annual goals are to be developed for each. These
annual goals will supplement the job-specific and hospital-wide performance standards, and are
intended to help identify the key performance goal for each individual employee that are not already
covered by the job-specific or hospital-wide standards. The first section below consists of the
individual annual goals developed for this employee for the past year. Please evaluate the degree to
which the goals were achieved. The sixth section below is where you should document the
employees individual goals for the coming year. The employees achievement of these individual
goals will be evaluated in following years performance appraisal.

Core Competencies Summary

Core Competencies
Score:
Leadership

Score:

1.2

2.5

3.8

5.0

Score:

1.2

2.5

3.8

5.0

Job Competencies Summary

Job Competencies
Score:
Interpersonal Skills
Customer Focus

Use of LifePak-20 Summary

Use of LifePak-20

Score:

1.2

2.5

3.8

5.0

Score:

1.2

2.5

3.8

5.0

Score:
Defib
Debrillation
Synchronized cardioversion
Lead selects
QRS vol., EKG size
Recording paper

12 Lead ECG Summary

12 Lead ECG
Score:
Order entry
Equipment
Skin preparation
Electrodes
Lead attachment
ECG machine
Quality ECGs and troubleshoot

Past Performance Goals

Goals

Score: / 5.0 30 %
Accomplishments

Rating

Weight

/5.0

Title:

Due:

Completed:

Milestone

Actual Results

Measurement

Actual Results

Goals

Accomplishments

Rating

Weight

/5.0

Title:

Due:

Completed:

Milestone

Actual Results

Measurement

Actual Results

Core Competencies

Employee Score:

Leadership
Creates an environment where employees are
encouraged to challenge themselves to meet
attainable goals.

Manager Score:

Employee Score:
Manager Score:
Outstanding
Exceeds Expectations
Meets Expectations
Below Expectations
Needs Improvement

/5.0
15%
/5.0 (100 %)

Self:
Comments:
Development Plan:

Job Competencies
Interpersonal Skills

Employee Score:

Manager Score:

Employee Score:
Manager Score:

/5.0
15%
/5.0 (100 %)

Is sensitive to the needs, feelings and capabilities of others. Approaches others in a non-threatening and
pleasant manner, and treats them with respect.
Excellent interpersonal skills. Always deals with others in a pleasant and respectful manner. Displays
sensitivity to the needs and concerns of others.
Very good interpersonal skills. Deals with others in a pleasant and respectful manner. Displays
sensitivity to the needs and concerns of others.
Good interpersonal skills. Usually deals with others in a pleasant and respectful manner. Considers
the needs and concerns of others.
At times, needs to be more sensitive to the needs, feelings and capabilities of others. Has not always
dealt with others in a pleasant and respectful manner.
Does not display good interpersonal skills, and often treats others with a lack of respect.

Self:
Comments:
Development Plan:

Customer Focus

Employee Score:
Manager Score:

/5.0 (100 %)

Is dedicated to meeting the expectations and requirements of internal and external customers; gets firsthand customer information and uses it for improvements in products and services; acts with customers in
mind; establishes and maintains effective relationships with customers and gains their trust and respect.
Even the best people may have only a few towering strengths, and some very good people have
none. The Learner is outstanding in this area, a model, one of the best you've ever seen people
might seek out this person for guidance in this area. A rare skill; a gift; anyone who knows this person
would rate this as a 'Towering Strength'.
The Learner has notable strength in this area; better than most. The Learner could be a coach in this
area. Might select this person for a team just for this special talent. A clear majority of people who
know him/her would agree with this rating.
The Learner does what is expected; about like most others. If everyone performed this well on key
skills, the organization would be competent and successful. Different raters might disagree on the
rating; some seeing it as a talent, some as a weakness.
Almost everyone has a few of these, i.e. not always up to standard on everything. The results have
fallen short, and opportunities have been missed because of this weakness. The Learner is working
on improving this competency. With normal development, this could be raised to at least "Skilled/OK".
There is serious, pressing need to improve in this area; it is hurting performance. The Learner doesn't
understand this area, doesn't accept the need, or doesn't know what to do about it. It remains an
issue; his/her career could be stalled or stopped. Almost everyone who knows him/her would agree
with this rating.
Self:
Comments:
Development Plan:

Use of LifePak-20

Score:

/5.0 (20 %)

Rating S-Satisfactory; N-needs more practice; U-unsatisfactory

Method of Verification W-Observe in Work; S-Observe simulation; T-test; O-Other
Competency

Demonstrates testing of
Defib unit according to
procedure.
Demonstrates technique
of defibrillation.
Demonstrates
techniques of
synchronized
cardioversion.

Method of
Verification

Date
Observed

Rating

Comments:

Initials

Score
/5.0

(20%)

(20%)

(20%)


(20%)

Demonstrates
monitoring patient using
various lead selects.
Demonstrates and
adjusts QRS vol. EKG
size, freeze and record
features.
Demonstrates changing
recording paper.

(10%)

(10%)

12 Lead ECG

Score:

/5.0 (20 %)

Rating S-Satisfactory; N-needs more practice; U-unsatisfactory

Method of Verification W-Observe in Work; S-Observe simulation; T-test; O-Other
Competency

Method of
Verification

Assures proper
documentation of order
& entered into Order
Entry.
Is familiar with the
equipment.
Demonstrates proper
skin preparation.
Properly attaches
electrodes by assuring
they are placed in the
correct inercostal spaces
Correctly attaches leads
Shows ability to properly
operate the ECG
machine and properly
enter required data,
using the M number
correctly
Demonstrate the ability
to obtain quality ECGs
and troubleshoot those
of poor quality.

Date
Observed

Rating

Comments:

Initials

Score
/5.0

(15%)

(20%)

(10%)

(15%)

(20%)

(10%)

(10%)

New Performance Goals

Goals
Title:

Weight

Due:

Milestone

Measurement

Development Plan
Development Objectives
Title:

Due:
Development Objectives
Title:

Due:

Manager Summary Comments

Employee Summary Comments

By signing below, I am indicating that I have read and understood this evaluation.

Signatures
Employee:

Date:

Direct Manager:

Date:

Succession Planning
Potential for Promotion

Rate this direct report on his/her readiness for

promotion by choosing the best option from the
list.

High Potential potential to move up 2-3 levels.

Promotable potential to move up 1 level.
Well placed in current role.
Needs development in current role.
Not acceptable in current role.
Too new to rate.

Timing of Next Promotion

Rate this direct report on his/her readiness for

promotion by choosing the best option from the
list.

Immediate ready for promotion.

Within 1 year.
Within 2 years.
Greater than 2 years.
Too new to rate.

Risk of Leaving

Rate this direct report's risk of leaving the

organization by choosing the best option from the
list.

None not likely to leave.

Low likely to leave within 5 years.
Medium likely to leave within 1 year.
High likely to leave within the year.
Too new to rate.

Reason for Leaving

Choose the best option from the list to describe

why you think this direct report may leave the
organization

Approaching retirement.
Lack of growth opportunities.
Returning to school.
Dissatisfied with compensation.
Other reason.
Not applicable.

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