Evaluation Tools and Student Clinical Records

A successful student not only demonstrates skill acquisition and mastery, but also presents an

appropriate professional demeanor as evidenced by their interpersonal skills. The college has

developed tools to help foster the student’s professional growth, as well as evaluate their

professional behavior and skill competency. These tools are listed and described below.

Examples of each of these tools is included in this section.

Performance Evaluation Record (Yellow form)

This form provides a quick reference for staff and students to view student progress on

completing required skill Performance Evaluations. The skills are arranged in order of

presentation during the program. The student is expected to complete skills during the term

presented and this will be documented in the Professional Performance Assessment. The last

page of the record lists skills that students should observe and assist with during their clinical

experience, but are not required to demonstrate competency through the formal skill

Performance Evaluation. Observation or assistance must be supported by documentation in

the Daily Clinical Activity Record.

The Performance Evaluation Record is to be placed in the front of the student’s clinical

notebook. It will be retained in the clinical notebook throughout their clinical experiences.

STUDENT NAME:_____________________________ CLASS YEAR:_________________

Student must demonstrate the ability to independently perform the following skills by the end of the term

under which they are listed. If the student has had sufficient practice they may have their ability to

independently perform skill evaluated prior to term listed. If staff or instructor must intervene or direct student

performance during the procedure the student has not demonstrated competency.

SPRING TERM / FIRST YEAR

PERFORMANCE EVALUATION Date Site

Breath Sounds

Oxygen Supply Systems

Oxygen Administration

Small Volume Nebulizer Therapy

MDI Administration

DPI Administration

Incentive Spirometry

Documentation and Goals Assessment

Pulse Oximeter Monitoring

SUMMER TERM / FIRST YEAR

Humidity and Aerosol Therapy

Vest Airway Clearance System (HFCWO)

PEP / Flutter Therapy

Tracheostomy and Stoma Care

FALL TERM / SECOND YEAR

Manual Resuscitation

End Tidal CO2 Monitoring

Endotracheal Suctioning

Monitoring Cuff Pressures

Pressure Support

STUDENT NAME:_______________________________ CLASS YEAR:_________________

WINTER TERM / SECOND YEAR

PERFORMANCE EVALUATION Date Site

Chest X-Ray Interpretation

Extubation

Initiation of NIPPV (BiPap)

Initiation Cont. Mechanical Ventilation(Adult)

Monitoring of Cont. Mech. Ventilation (Adult)

Spontaneous Ventilation Parameters

STUDENT NAME:_______________________________ CLASS YEAR:_________________

Students are not required to complete the checklists for the skills listed below but should observe and

eventually assist staff in the performance of the techniques, according to the policy and procedures of the

clinical site. Student may be able to perform some skills under direct supervision of clinical staff.

Date / Site Date / Site

PERFORMANCE EVALUATION OBSERVED ASSISTED/ OR

PERFORMED WITH

SUPERVISON

Oxygen Concentrator

Equipment Processing

Liquid Oxygen Systems

Bedside PFT (VC & PF)

Chest Percussion / Postural Drainage

Adjunct Breathing Techniques

IPPB

Nasotracheal Suctioning

Basic Spirometry

Electrocardiographs

Arterial Puncture

Arterial Line Sampling

Intubation

Extended Mandatory Minute Ventilation

Changing a Ventilator Circuit

Initiation of Newborn Mechanical Ventilation

Monitoring of Newborn Mechanical Ventilation

CVP/Pulmonary Artery Catheter Monitoring

Arterial Line Monitoring

Bronchoscopy Assisting

The Daily Activity Record/Preceptor Feedback Form (White form)

The student will complete this form for each clinical day. It must include their name, clinical

site, date, and the times they arrived and departed the clinical site. This includes any shift that

was missed (with an explanation), and any make-up shift. These sheets provide an area for

them to track the activities of the shift, list other learning experiences or discussions they had

with their preceptor. The back side of the form is for your preceptor to complete. It provides

clinical preceptors the opportunity to evaluate the student in several categories (Coming

Prepared, Professional Behavior, Technical Performance, and Communication Skills) and to

provide feedback directly to program faculty. There are yes/no questions and an area for

detailed comments on the students’ strengths and areas to work on. There is also a check box

to indicate if the preceptor discussed their feedback with the student. The preceptor’s signature

is required. It is important that these are completed PRIOR to leaving the clinical site for the

day. This ensures a correct record of the events of the day as well as the site documentation

that is necessary for this to be a valid record.

Daily Clinical Activity Record Student is required to complete the following information and to present to instructor/preceptor at

conclusion of day for review and verification.

Name: ___________________________ Clinical Site: ____________________________

Date: ________________ Time In: _________ Time Out: _________

Indicate how many times you participated in the following technical skills/activities/procedures. The (Term) indicates when

skill needs to be completed & checked off. Once completed these skills should be performed regularly with minimal supervision.

# of Times Observed

# Assisted with supervision

Oxygen Supply Systems (Spring Term)

Oxygen Administration (Spring Term)

Small Volume Nebulizer Therapy (Spring Term)

MDI Administration (Spring Term)

DPI Administration (Spring Term)

Incentive Spirometry (Spring Term)

Documentation and Goals Assessment (Spring Term)

Pulse Oximeter Monitoring (Spring Term)

Humidity and Aerosol Therapy (Summer Term)

Vest Airway Clearance System (HFCWO) (Summer Term)

Pep/Flutter Therapy (Summer Term)

Manual Resuscitation (Summer/Fall Term)

Initiation of NIPPV (BIPAP) (Summer Term)

End Tidal CO2 Monitoring (EtCO2) (Fall Term)

Endotracheal Suctioning (Fall Term)

Monitoring Cuff Pressures (Fall Term)

Tracheostomy and Stoma Care (Fall Term)

Pressure Support (Fall Term)

Chest X-ray Interpretation (Fall Term)

Extubation (Fall/Winter Term)

Initiation of Cont. Mech.Ventilation (Adult) (Neo)

(Fall/Winter Term)

Monitoring of Cont. Mech. Vent. (Adult) (Neo)

(Fall/Winter Term)

Spontaneous Ventilation Parameters (Fall/Winter Term)

Other Learning Experiences:

What Questions arose during your shift and what discussions did this spark with your preceptor?

Please Indicate:

Student Strengths:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

_________________________________________________________________

Student Needs for Improvement:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

_________________________________________________________________

______Initial here if: I have reviewed this evaluation with this student.

______Initial here if: I have forwarded this information on to the Director of Clinical Education or my Supervisor.

(Print) Preceptors Name__________________________PreceptorsSignature_____________________________

Comes Prepared:

YES NO Complied with hospital, college dress codes, used appropriate identification.

YES NO Arrived prepared to carry out assigned tasks with necessary equipment & paperwork.

YES NO Appropriately applied / integrated theory, principles to clinical practice.

Professional Behavior:

YES NO Took direction, instruction, suggestions and ideas in a cooperative manner.

YES NO Appropriately sought assistance when needed, realizes personal limitations.

YES NO Sought out educational opportunities for professional development.

Technical Performance:

YES NO Planed, organized, fulfilled tasks assigned by instructor / supervisor.

YES NO Provided therapy based on therapist driven protocols and/or appropriate physician order

YES NO Competently performed assigned tasks & procedures ensuring safe delivery of patient care.

Communication Skills:

YES NO

Used appropriate communication to relate effectively to patients, instructors, peers, staff. Demonstrated appropriate verbal & nonverbal communication.

YES NO Adhered to HIPPA requirements.

YES NO Maintained accurate & timely departmental & patient records.

Physician Interaction Record (Teal Card) Documentation of time interacting with the physician is necessary to meet program accreditation

standards. Physician interaction could be patient focused, tutorial, or small or large group sessions. The

student is awarded points based on the type of physician interaction. The number of physician

interactions increases as the student advances through each clinical practice sequence:

Clinical Practice 1 . . . minimum of 2 separate physician interactions

Clinical Practice 2 . . . minimum of 4 separate physician interactions

Clinical Practice 3 . . . minimum of 6 separate physician interactions

Clinical Practice 4 . . . minimum of 8 separate physician interactions

Lane Community College Name

Respiratory Care Program Physician Interaction Form Clinical Site Physician Name________________________________________________________

Topic________________________________________________________________

Type of Interaction:

Patient Focused: Date___________________

Tutorial: Time Spent: _____________

Small Group: Points Awarded: _________

Large Group:

Evaluation of Student – Physician Interaction

Instructions: Please circle the response that reflects your evaluation of this learning experience using the following criteria:

5 = Strongly Agree 4= Agree 3=Disagree 2= Strongly Disagree 1= N/A

Student Evaluation of Physician Interaction

1) The information was presented at a level appropriate for my experience. 5 4 3 2 1

2) The information was covered completely and at a reasonable pace. 5 4 3 2 1

3) This interaction was a positive experience. 5 4 3 2 1

4) The information was relevant to my clinical work. 5 4 3 2 1

5) The physician took time to explain principles relevant to the practice of 5 4 3 2 1

respiratory care.

6) The physician was receptive to discussion and student participation. 5 4 3 2 1

7) The interaction improved my communication skills with physicians. 5 4 3 2 1

Physician Evaluation of Student Interaction

1) The student has a good understanding of the information presented. 5 4 3 2 1

2) The student provided accurate objective data. 5 4 3 2 1

3) The student used appropriate medical terminology. 5 4 3 2 1

4) The student provided appropriate subjective information. 5 4 3 2 1

5) The student could explain relevant principles of practice. 5 4 3 2 1

6) The student answered directly and appropriately. 5 4 3 2 1

7) The student was able to suggest well-reasoned alternatives. 5 4 3 2 1

8) The student was receptive to feedback. 5 4 3 2 1

Students should seek out physician interaction whenever possible in order to learn the

appropriate physician-therapist rapport. A point system has been created to encourage

this behavior. Students must earn a total of 10 points per term. The scoring system is listed below.

Type A: Patient Focused

Individual personal interaction with a physician relating to the management of a particular

Patient as it pertains to respiratory care. Included are actual procedures with a patient (for example, code

blue, bronchoscopy, etc.). Also included are such activities as evaluations, diagnosis, treatment plans,

and prognosis of a singular patient.

Type B: Tutorial

Individual, one-on-one instruction related to clinical medicine or other areas pertinent to

respiratory care. Included are activities such as formal or informal discussions, review of research or

recent advances in respiratory care and practical demonstration of procedures

and equipment without patient interaction.

Type C: Small Group

Formal or informal presentations such as inservice, seminars, continuing education meetings, case

presentations, physicians rounds, etc. It is necessary for the presentations to be small

Enough for the physician conducting the session to be aware of who is in attendance.

Type D: Large Group

Formal education experiences such as lectures papers presented at professional meetings, conferences,

seminars, etc. The size of the meeting would preclude significant audience participation.

Scoring as follows:

Type A : 1 hour = 4 points

Type B : 1 hour = 3 points

Type C : 1 hour = 2 points

Type D: 1 hour = 1 point

Note:

Physician interaction records are to be submitted to the Director of Clinical Education or Program

Coordinator at the time of Personal Performance Assessment.

Performance (Skill) Evaluation Checklists

The Performance Evaluation Checklists from Basic Clinical Lab Competencies for Respiratory

Care are the tools used to evaluate student competency. Ideally, the student should have

practiced the procedures in the laboratory setting. When they feel capable of properly

demonstrating the procedure, they should enlist the help of a peer who will observe and rate

their performance. When they have passed the peer evaluation they should ask the lab

instructor to evaluate their performance.

Clinical skill evaluation should be preceded by observation of staff, assisting staff in performing

the procedure, and close supervision by staff while practicing the procedure. When the student

feels capable of performing procedure without staff assistance they should ask to be formally

evaluated using the Performance Evaluation Checklist for that skill. Student should review

checklist with evaluator so that site-specific procedural differences are addressed before the

skill evaluation. Evaluator should intervene in procedure only if patient safety is compromised.

Criteria for receiving a passing score on the evaluation are given on the checklist. A student

who fails to receive a passing score may request a repeat evaluation after further supervised

practice.

Successful completion of a skill evaluation indicates that the student is competent at

performing that skill and requires minimal supervision. Proficiency in performing the skill is only

achieved through further practice, which must be documented on the Daily Clinical Activity

Record.

Professional Performance Assessment

Respiratory Care students are legally responsible for their own acts, commission and/or

omission. The student, the faculty, and clinical site staff must conscientiously evaluate student

behavior. The Professional Performance Assessment (PPA) evaluation identifies essential

areas of behavior that indicate the successful demonstration of appropriate professional

behavior and interpersonal skills: Attendance, Preparedness, Professional Behavior, Technical

Performance, and Communication Skills.

The PPA serves to reinforce and encourage appropriate student behavior, as well as a means

to document unsafe, unacceptable behaviors. Unsafe, unacceptable behaviors will require the

immediate completion of a PPA by the preceptor. The preceptor must provide written

explanation of any “Needs Improvement” ratings. The student is to review the assessment with

the preceptor or supervisor, and acknowledge this by signing the assessment form. A copy is

to be given to the student for their notebook, and the original is to be forwarded to the Director

of Clinical Education for LCC. Periodically during the term, and at the conclusion of each

clinical course, a PPA will be completed for each student by LCC program faculty utilizing the

input received from the Preceptor’s Daily Feedback forms / PPA’s. Notice of failing behavior

will be forwarded from one instructor to the next instructor to ensure that students will be given

the encouragement, support, and limit-setting to facilitate the learning of these essential

professional behaviors. Any behavior that results in an unsatisfactory rating in any one term, if

repeated in a subsequent term, can result in immediate exclusion from further clinical

experience.

The PPA serves as the written warning prior to suspension from clinical activities as required

by LCC Respiratory Care Program Policy as indicated in the Student Orientation Manual.

Immediate suspension for violations of the student rules of conduct is still possible. The

Director of Clinical Education or Program Director must be notified immediately following

suspension of student privileges by the clinical site.

PROFESSIONAL PERFORMANCE ASSESSMENT

Behaviors relating to responsibility, accountability, and meeting time commitments are essential in the

professional respiratory practitioner. Students who always demonstrate these behaviors should receive

(E)xcellant ratings. Students who usually demonstrate these behaviors should receive (S)atisfactory ratings.

Students who demonstrate unsafe and unprofessional behavior will result in (N)eeds Improvement ratings, and

must have behavior documented on evaluation.

(Evaluation criteria are noted on the back of this form.)

Constructive criticism is a valuable learning tool so please include suggestions for improvement.

_______________________________________________ ______________________________

Evaluator’s Signature Date of Evaluation

I have reviewed the above evaluation and understand that areas rated as Needs Improvement are to be corrected immediately.

This evaluation constitutes a written warning of unacceptable behavior. Failure to correct this behavior can result in a failing

grade for this course.

_______________________________________________ ______________________________

Student’s Signature Date

Area Evaluated E S N Suggestions for Improvement

Attendance

Comes Prepared for Clinical

Rotation

Professional Behavior

Technical Performance

Communication Skills

Please consider the following criteria when evaluating student performance:

Attendance: Arrives early enough to start on time

Seeks permission to leave from appropriate supervisor

Gives appropriate and prompt notification regarding absence.

Comes Prepared for Clinical: Complies with hospital and college dress codes, and use of identification

Arrives at facility prepared to carry out assigned tasks with necessary equipment / paperwork

Appropriately applies / integrates theory and principles to clinical practice

Professional Behavior: Courteous / considerate with peers, staff, patients and other hospital personnel

Takes direction, instruction, suggestions and ideas made by those in authority in a cooperative

manner

Seeks appropriate assistance when needed, realizes personal limitations

Assumes responsibility for learning by seeking out educational opportunities (self-direction)

Follows rules of conduct listed in student orientation manual

Technical Performance: Adheres to hospital policies and procedures for safe delivery of patient care

Plans, organizes, and fulfills the tasks assigned by instructor / supervisor

Provides therapy based on therapist driven protocols and/or appropriate physician order

Attains minimal technical competency in assigned skills

Conserves and safeguards hospital materials and property

Communication Skills: Uses appropriate communication style to relate effectively to patients, instructors, peers, and staff

Maintains accurate records in a timely fashion

Respects confidential nature of hospital records and patient information. Adheres to HIPA

requirements.

End-of-term Employer Survey

The Director of Clinical Education will request completion of the End-of-term Employer Survey

by the department manager. This survey is reviewed with the student with suggestions for

improvement if needed.

End-of-Term Employer Survey

Lane Community College

Respiratory Care Program

Please help us identify students at risk of not successfully completing the program by answering the following

questions regarding the student named on this form. We will use this information to develop an individual plan

with the student to address areas of needed improvement.

Name of Student: Date:

1. Is this student welcome back for further clinical experience? Yes No

If no, please explain:

2. How would you rate the employability of this student?

Excellent Very Good Good Fair Poor

What can they work on to improve this rating?

Clinical Site Evaluation

Student completes the clinical site evaluation at the end of each term. Results are shared with

the clinical site manager.

Lane Community College

Respiratory Care Program

TERM: YEAR: CLASS OF:

CLINICAL SITE: SHIFT: AREA OF ROTATION:

DIRECTIONS: This form should be completed at the end of each clinical rotation. Student evaluations are kept on file at the College. Program faculty and its advisory committee review this data. Your objective view is very important to our on-going program evaluation and development. Consider each item separately and rate each item independently of all others. Circle the rating that indicates the extent to which you agree with each statement. Please do not skip any rating. Please comment if a score of 4 or 5 is given to help us further identify areas for improvement.

Strongly Generally Neutral Generally Strongly Agree Agree (Acceptable) Disagree Disagree

1 2 3 4 5

The clinical resources for this rotation were adequate to help me meet course objectives.

1 2 3 4 5

Comment:

I felt adequately supervised during the rotation.

1 2 3 4 5

Comment:

The quality of clinical instruction was adequate.

1 2 3 4 5

Comment:

The staff / preceptor / clinical instructor facilitated experiences that contributed to the completion of Performance Evaluations required for this course.

1 2 3 4 5

Comment:

Orientation to assigned clinical areas, and procedures was adequate.

1 2 3 4 5

Comment:

Staff / preceptors / clinical instructors are readily available to assist me when needed.

1 2 3 4 5

Comment:

Staff / preceptors / clinical instructors provided consistent, constructive, and timely feedback regarding my clinical performance. 1 2 3 4 5

Comment:

Points I felt were the strongest in this rotation:

Points I felt were the weakest:

If you could improve your clinical experience in any way, what changes would you make:

THANK YOU!