Clinical Evaluation 1
Student:
Instructor:
Kapiolani Community College
Associate in Science Degree Nursing Program
NURS 360 Health & Illness I
CONCEPT: CLINICAL JUDGMENT
Mid-term/Final Clinical Evaluation Tool Scoring Rubric
Instructions: Clinical judgment is developed. The students performance of each element may be determined to be failing,
needs improvement, or satisfactory and passing. At mid-term, all elements must meet the standard performance of Needs
Improvement and/or Pass. Any element at mid-term that is a Fail will constitute a failure in the clinical portion of the
course; and result in the student not being allowed to continue in clinical. By the end of the course, the student is expected to
perform satisfactorily and earn Pass for each element. If any element is evaluated as Needs Improvement at the end of the
course, the final clinical evaluation will be clinical failure.
ELEMENT
Effective NOTICING
involves:
N360 Pass
N360 Needs Improvement
N360 Non-Pass
Useful information is noticed, sees
the most subtle signs.
Regularly observes/monitors a variety of
data, including both subjective and objective;
most useful information is noticed, may miss
the most subtle signs.
Recognizes subtle patterns and
deviations from expected patterns in
data and uses these to guide the
assessment
Recognizes most obvious patterns and
deviations in data and uses these to
continually assess
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
Assertively seeks information to
plan intervention: carefully collects
useful subjective data from
observing the client and from
interacting with the client and family
Actively seeks subjective information about
the clients situation from the client and
family to support planning interventions;
occasionally does not pursue important leads
Focused Observation
Recognizing
Deviations from
Expected Patterns
Information Seeking
Makes limited efforts to seek
additional information from the
client/family; often seems not to
know what information to seek
and/or pursues unrelated
Clinical Evaluation 2
information
Clinical Evaluation 3
ELEMENT
Effective
INTERPRETING
involves:
Prioritizing Data
Making Sense of
Data
N360 Pass
N360 Needs Improvement
N360 Non-Pass
Focuses on the most relevant and
important data useful for explaining
the clients condition
Generally focuses on the most important data Makes an effort to prioritize data
and seeks further relevant information, but
and focus on the most important,
also may try to attend to less pertinent data
but also attends to less
relevant/useful data
Even when facing complex,
conflicting or confusing data, is able
to (1) note and make sense of
patterns in the clients data, (2)
compare these with known patterns
(from the nursing knowledge base,
research, personal experience, and
intuition), and (3) develop plans for
interventions that can be justified in
terms of their likelihood of success
In most situations, interprets the clients data
patterns and compares with known patterns
to develop an intervention plan and
accompanying rationale; the exceptions are
rare or complicated cases where it is
appropriate to seek the guidance of a
specialist or more experienced nurse
In simple or common/familiar
situations, is able to compare the
clients data patterns with those
known and to develop/explain
intervention plans; has difficulty,
however, with even moderately
difficult data/situations that are
within the expectations for
students, inappropriately requires
advice or assistance
Clinical Evaluation 4
ELEMENT
Effective
RESPONDING
involves:
Calm, Confident
Manner
Clear Communication
Well-Planned
Intervention/Flexibilit
y
Being Skillful
N360 Pass
N360 Needs Improvement
Assumes responsibility: delegates
team assignments, assess the client
and reassures them and their
families
Generally displays leadership and
confidence, and is able to control/calm most
situations; may show stress in particularly
difficult or complex situations
Communicates effectively; explains
interventions; calms/reassures
clients and families; directs and
involves team members, explaining
and giving directions; checks for
understanding
Generally communicates well; explains
carefully to clients, gives clear directions to
team; could be more effective in
establishing rapport
Interventions are tailored for the
individual client; monitors client
progress closely and is able to
adjust treatment as indicated by the
client response
Shows mastery of necessary nursing
skills
Develops interactions based on 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
N360 Non-Pass
Is tentative in the leaders role;
reassures clients/families in
routine and relatively simple
situations, but becomes stressed
and disorganized easily
Shows some communication
ability (e.g., giving directions);
communication with
clients/families/team members is
only partly successful; displays
caring but not competence
Develops interventions based on
the most obvious data; monitors
progress, but is unable to make
adjustments based on the patient
response
Is hesitant or ineffective in
utilizing nursing skills
Clinical Evaluation 5
ELEMENT
Effective
REFLECTING
involves:
Evaluation/SelfAnalysis
Commitment to
Improvement
N360 Pass
Independently evaluates/
analyzes personal clinical
performance, noting decision points,
elaborating alternatives and
accurately evaluating choices
against alternatives
Demonstrates commitment to
ongoing improvement: reflects on
and critically evaluates nursing
experiences; accurately identifies
strengths/weaknesses and develops
specific plans to eliminate
weaknesses
N360 Needs Improvement
Evaluates/analyzes personal clinical
performance with minimal prompting,
primarily major events/decisions; key
decision points are identified and
alternatives are considered
Demonstrates a desire to improve nursing
performance: reflects on and evaluates
experiences; identifies
strengths/weaknesses; could be more
systematic in evaluating weaknesses
N360 Non-Pass
Even when prompted, briefly
verbalizes the most obvious
evaluations; has difficulty
imagining alternative choices; is
self-protective in evaluating
personal choices
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
Clinical Evaluation 6
Midterm
Student
Pass / NI
Pass / NI
Pass / NI
Midterm
Faculty
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Final
Student
Pass / Fail
Pass / Fail
Pass / Fail
Final
Faculty
Pass / Fail
Pass / Fail
Pass / Fail
Pass / NI
Pass/NI/Fail
Pass / Fail
Pass / Fail
2. Interpreting:
2.1 Prioritizing Data
2.2 Making Sense of Data
Pass / NI
Pass / NI
Pass / NI
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
3. Responding:
3.1 Calm, Confident Manner
3.2 Clear Communication
3.3 Being Skillful
3.4 Being Caring
3.5 Accepting feedback from others
Pass / NI
Pass / NI
Pass / NI
Pass / NI
Pass / NI
Pass / NI
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
4. Reflecting:
4.1 Evaluation of Response of Client
4.2 Evaluation/Self-Analysis
4.3 Commitment to Improvement
Pass / NI
Pass / NI
Pass / NI
Pass / NI
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
5. Professionalism:
5.1 Meeting Deadlines
5.2 Attendance
5.3 Policy
Pass / NI
Pass / NI
Pass / NI
Pass / NI
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass/NI/Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Pass / Fail
Clinical Judgment/Reasoning
1. Noticing:
1.1 Focused Observation
1.2 Recognizing Deviations from
Expected Outcomes
1.3 Information Seeking
Kapiolani Community College
Associate in Science Degree Nursing Program
NURS 360 Health & Illness I
Clinical Evaluation
Clinical Evaluation 7
NURS 360 Clinical Evaluation Summary
Mid-Term Clinical Evaluation Summary
Student Comments & Plans for Improvement:
So far in our med surg rotation, I am appreciative of the opportunity and privilege to provide care for multiple
patients. It is a new experience to work with more than one and very critical to my learning as it allows me the
opportunity to develop time management skills and incorporate repetition into my nursing skills. I look forward to
refining my fundamental nursing skills by continuing to apply the nursing process and my evolving nursing judgment
in all interactions and plans of care for each patient. I will continue to attend my rotations with an open attitude and
work to increase my nursing confidence.
Clinical Evaluation 8
Self Evaluation:
Pass / Needs Improvement
Student Signature
Date
Faculty Evaluation:
Pass / Needs Improvement / Failure
Faculty Comments & Suggestions for Improvement:
____________________________________________________
Student Signature
Date
Faculty Signature
Date
Final Clinical Evaluation Summary
Student Comments:
From the start until now of our med surg II rotations, I feel that Ive made very meaningful gains in my nursing
practice. Concepts that weve been introduced to even as far back as our nursing program prerequisite courses continue
to resurface with a different, more refined meaning. My clinical experience this semester has been the most impactful to
motion within my academic pursuit, and the stress at times was discouraging. But here I am, still in the race to beat
project deadlines and pass examinations on this last leg of the program. I was doubtful at times. The thing that I am
most thankful for is the opportunities that Ive had to practice my critical thinking skills in care plan development and
implementation.
Self Evaluation:
Pass / Failure
Student Signature
Faculty Evaluation:
Date
Pass / Failure
Faculty Comments
____________________________________________________
Student Signature
Date
Clinical Evaluation 9
Faculty Signature
Date