Brigham Young University Idaho Nursing Program Clinical Evaluation Tool

To be completed by Student:
Student Name: Taylor Garner

I#: 54-700-2541
Course code:

Facility Name:
Ashton
Clinical Area:

Dates Attended: 6/9/97

To be complete by Clinical facilitator/preceptor:

Clinical facilitator/preceptor name: Sis Cannon

Number of hours completed:

Number of hours absent:
Mid-term assessment: Satisfactory
Unsatisfactory
Final assessment: Satisfactory X
Unsatisfactory
Clinical facilitator/preceptors signature: L Cannon RN

Date: 6/9/17

I acknowledge that I have made a duplicate of this document and other documents that I have submitted which I will retain for the duration of my course.

Students signature:_____________________________________________ Date:________________________

Revised 7/18/16
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool

Daily: Mid-term: Final:

Student Self Evaluation Complete a self-assessment in the section of the Clinical Evaluation Tool based on your clinical experience, and meet with
your assigned clinical faculty to discuss. Use the next page to determine your self-rating and explain specifically your
rationale or give examples if you gave yourself a rating below or above the minimum requirements for your semester level.
Clinical Judgment Component
NOTICING
Focused Observation E A D B U B
Recognizing deviations from B
expected patterns E A D B U
Information Seeking E A D B U B
INTERPRETING
Prioritizing Data: E A D B U B
Making sense out of data: E A D B U B
RESPONDING
Calm, Confident Manner E A D B U B
Clear Communication E A D B U B
Well-Planned Intervention/ B
Flexibility E A D B U
Being Skillful E A D B U B
REFLECTING
Evaluation/Self-Analysis E A D B U B
Commitment to Improvement E A D B U B

Minimum requirements Jnr 1 (NURS Jnr 2 (NURS 322C & NURS Snr 1 (NURS 410C & NURS 422C) Snr 2 (NURS433C &
per semester 310C) 323C) NURS490C
Noticing B D A A
Interpreting B D A A
Responding B D A A
Reflecting B D A A
Copy permission obtained from Lasater (U:\SON\Diane\Bussard\Lasater Clinical Judgment Rubric Scoring Sheet.doc) Final document adapted from Lasater (2007a)

Revised 7/18/16
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
Table 1: Adapted Lasater Clinical Judgment Rubric
Dimension Exemplary
Effective noticing involves:
Focused observation Focuses observation appropriately
without assistance; regularly
observes and monitors a wide
variety of objective and subjective
data to uncover any useful
information and makes changes to
assessments as needed.
Recognizing deviations Recognizes subtle patterns and
from expected patterns deviations from expected patterns
in data and uses these to guide the
assessment. Makes association
between deviations to patient
disease processes.
Information seeking Assertively seeks information to plan
intervention: carefully collects useful
subjective data from observing and
interacting with the patient and
family. Determines if more
information is needed.
Effective interpreting involves:
Prioritizing data Focuses on and prioritizes the most
relevant and important data useful
for explaining the patients
condition.
Making sense of data Even when facing complex,
conflicting, or confusing data, is able
to (a) note and make sense of
patterns in the patients data, (b)
compare these with known patterns
(from the nursing knowledge base,
research, personal experience, and
intuition), and (c) develop plans for
interventions that can be justified in
terms of their likelihood of success.
Seeks new data as needed.
Effective responding involves:
Revised 7/18/16
Accomplished
Focuses observation appropriately;
regularly observes and monitors a
wide variety of objective and
subjective data to uncover any useful
information.
Recognizes subtle patterns and
deviations from expected patterns in
data and uses these to guide the
assessment.
Assertively seeks information to plan
intervention: carefully collects useful
subjective data from observing and
interacting with the patient and
family.
Focuses on the most relevant and
important data useful for explaining
the patients condition.
Even when facing complex,
conflicting, or confusing data, is able
to (a) note and make sense of
patterns in the patients data, (b)
compare these with known patterns
(from the nursing knowledge base,
research, personal experience, and
intuition), and (c) develop plans for
interventions that can be justified in
terms of their likelihood of success.
Developing
Regularly observes and
monitors a variety of data,
including both subjective and
objective; most useful
information is noticed; may
miss the most subtle signs.
Recognizes most obvious patterns
and deviations in data and uses
these to continually assess.
Actively seeks subjective
information about the patients
situation from the patient and
family to support planning
interventions; occasionally does
not pursue important leads.
Generally, focuses on the most
important data and seeks further
relevant information but also
attempts to attend to less
pertinent data.
In most situations, interprets the
patients data patterns and
compares with known patterns to
develop an intervention plan and
accompanying rationale; the
exceptions are rare or in
complicated cases where it is
appropriate to seek the guidance
of a specialist or a more
experienced nurse.
Beginning
Attempts to monitor a variety
of subjective and objective data
but is overwhelmed by the
array of data; focuses on the
most obvious data, missing
some important information.
Identifies obvious patterns and
deviations, missing some
important information; unsure
how to continue the assessment.
Makes limited efforts to seek
additional information from
the patient and family; often
seems not to know what
information to seek and/or
pursues unrelated
information.
Makes an effort to prioritize and
focus on the most important
data, but also attends to less
relevant or useful data.
In simple, common, or familiar
situations, is able to compare
the patients data patterns with
those known and to develop or
explain intervention plans; has
difficulty, however, with even
moderately difficult data or
situations that are within the
expectations of students;
inappropriately requires advice
or assistance.
Unsatisfactory
Confused by the clinical
situation and the amount and
kind of data; observation is not
organized and important data
are missed, and/or assessment
errors are made
Focuses on one thing at a time
and misses most patterns and
deviations from expectations;
misses opportunities to refine
the assessment
Is ineffective in seeking
information; relies mostly on
objective data; has difficulty
interacting with the patient and
family and fails to collect
important subjective data
Has difficulty focusing and
appears not to know which
data are most important to
the diagnosis; attempts to
attend to all available data
Even in simple, common, or
familiar situations, has difficulty
interpreting or making sense of
data; has trouble distinguishing
among competing explanations
and appropriate interventions,
requiring assistance both in
diagnosing the problem and
developing an intervention
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
Table 1: Adapted Lasater Clinical Judgment Rubric
Dimension Exemplary
Calm, confident manner Assumes responsibility within
current scope of practice; assesses
patients efficiently and effectively.
Reassures patient and any support
persons, adjust priorities of care
based on changes to patient
condition.
Clear communication Communicates effectively; checks
for understanding and adjusts
communication as needed; explains
interventions in a manner that all
involved are able to understand;
calms and reassures patients and
any support persons;
Well-planned Interventions are tailored for the
intervention/flexibility individual patient; monitors patient
progress closely and is able to
adjust treatment as indicated by
patient response and by worsen
patient condition.
Being skillful Shows confidence and co-
ordination of necessary nursing
skills with minimal supportive cues
from staff or faculty.
Effective reflecting involves:
Evaluation/self-analysis Independently evaluates and
analyzes personal clinical
performance, noting decision
points, elaborating alternatives,
and accurately evaluating choices
against alternatives. Assesses if
goals are being met.
Revised 7/18/16
Accomplished
Assumes responsibility within
current scope of practice; delegates
team assignments; appropriately
assesses patients and reassures
reassure the patient and any
support persons.
Communicates effectively; explains
interventions; checks for
understanding calms and reassures
patients and any support persons.
Interventions are tailored for the
individual patient; monitors patient
progress closely and is able to adjust
treatment as indicated by patient
response.
Shows confidence and capability of
necessary nursing skills, requires
infrequent supportive cues from
staff or faculty.
Independently evaluates and
analyzes personal clinical
performance, noting decision points,
elaborating alternatives, and
accurately evaluating choices against
alternatives.
Developing
Needs to be prompted to take
responsibility. Appears to be
unsure of appropriate co-
ordination of care. Is able to
assess the patient, requires
assistance to priorities care but
is able to appropriately reassure
the patient and any support
persons.
Generally, communicates well;
explains carefully to patients and
any support persons; could be
more effective in establishing
rapport.
Develops interventions on the
basis of relevant patient data;
monitors progress regularly but
does not expect to have to
change treatments.
Displays proficiency in the use of
most nursing skills; could
improve speed or accuracy,
requires frequent verbal and/or
physical cues.
Evaluates and analyzes personal
clinical performance with
minimal prompting, primarily
about major events or decisions;
key decision points are
identified, and alternatives are
considered.
Beginning
Is reluctant to take on
responsibility; reassures patients
and families in routine and
relatively simple situations, but
becomes disorganized easily,
unable to adjust to changes in
patients conditions.
Shows some communication
ability (e.g., giving directions);
communication with patients,
and any support persons is only
partly successful; displays some
empathy.
Develops interventions on the
basis of the most obvious data;
monitors progress but is unable
to make adjustments as indicated
by the patients response.
Is hesitant or ineffective in using
nursing skills, requires
continuous verbal and frequent
physical cues.
Even when prompted, briefly
verbalizes the most obvious
evaluations; has difficulty
imagining alternative choices;
is self-protective in evaluating
personal choices.
Unsatisfactory
Except in simple and routine
situations, is stressed and
disorganized, lacks control,
makes patients and families
anxious or less able to
cooperate
Has difficulty
communicating;
explanations are confusing;
directions are unclear or
contradictory; patients and
families are made confused
or anxious and are not
reassured
Focuses on developing a single
intervention, addressing a likely
solution, but it may be vague,
confusing, and/or incomplete;
some monitoring may occur
Is unable to select and/ or
perform nursing skills
Even prompted evaluations are
brief, cursory, and not used to
improve performance; justifies
personal decisions and choices
without evaluating them
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
Table 1: Adapted Lasater Clinical Judgment Rubric
Dimension Exemplary Accomplished Developing Beginning Unsatisfactory

Commitment to Demonstrates commitment to
improvement ongoing improvement; reflects on
and critically evaluates nursing
experiences; accurately identifies
strengths and weaknesses and
develops specific plans to eliminate
weaknesses. Uses reflective nursing
practice effectively.
Demonstrates commitment to
ongoing improvement; reflects on
and critically evaluates nursing
experiences; accurately identifies
strengths and weaknesses and
develops specific plans to eliminate
weaknesses.
Demonstrates a desire to
improve nursing performance;
reflects on and evaluates
experiences; identifies
strengths and weaknesses;
could be more systematic in
evaluating weaknesses.
Demonstrates awareness of the
need for ongoing improvement
and makes some effort to learn
from experience and improve
performance but tends to state
the obvious and needs external
evaluation.
Appears uninterested in
improving performance or is
unable to do
so; rarely reflects; is
uncritical of himself or
herself or overly critical
(given level of development);
is unable to see flaws or
need for improvement

Table 2
Resource for Students: Examples of questions from the Lasater Clinical Judgment Rubric (LCJR) that simulate deep thinking and learning so student think like a nurse.
Tanner Model Phase LCJR Dimension Example of Question
Noticing Focused observations What did you first notice about the patient?
Recognizing deviations from expected What was different than what you expected? Have you seen this before in other
patterns patients?
Information seeking What other information would be helpful? How can you get that information?
Interpreting Prioritizing data How did you prioritize the patient information/data? In other words, what was most
important for this patient now?
Making sense of the data On what did you base choice of intervention? If intuition, what kinds of data might offer
evidence to support your gut feeling?
Responding Calm, confident manner What was your approach with the patient? How comfortable did you feel?
Clear communication How did you think you gained the patients trust? What did you say to the patient? To
the family?
Well-planned interventions/flexibility What factors, including patient feedback, impacted the treatment plan?
Being skillful How did your skill compare to nursing standards of care?
Reflecting Evaluation/self-analysis What went well? What didnt go so smoothly as your planned? Why or why not?
Commitment to improvement What would you do differently if you had the opportunity?
K. Lasater / Nurse Education in Practice 11 (2011) 86e92

Students and facilitators are expected to complete an interim and a final reflection on the clinical placement.

Mid-term reflection by student: Mid-term reflection by facilitator/clinical preceptor

Revised 7/18/16
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool

Students name:_______________________ Students signature ___________________________ Date:____________________________

Clinical facilitator/preceptor name:_______________________ Clinical facilitator/preceptor signature:_______________________ Date:________________

Final reflection by student: Final reflection by facilitator/preceptor:

I think I have improve on my therapeutic communication with my patients.
I have improved on seeking extra information from patients.
I agree, I think you have improved a lot during this rotation and you are ready
to move on to next semester. I want you to remember that you are the only
one that can make your learning worthwhile so seek learning opportunities at
all times and dont waste your time. Be confident and patient with yourself,
learning takes time and the more you do something the easier it becomes.
Good job!

I have improved my skills and my head to toe assessment.

Students name:_______________________ Students signature ___________________________ Date:____________________________

Revised 7/18/16
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
Clinical facilitator/preceptor name:_______________________ Clinical facilitator/preceptor signature:_____L Canon RN___________ Date:________________

Revised 7/18/16