Area to be Evaluated	Outstanding	Above Average	Average	Needs Improvement	Unacceptable	Not Observed	Comments
KNOWLEDGE:	Consistently	Differentiates	Demonstrates	Recalls	Major	Not
General	evaluates	understanding of	understanding	understanding of	deficiencies in	observed
	therapeutic	basic	of basic	basic concepts	knowledge
	interventions,	Pathophysiology	Pathophysiolog		base
	broad based		y
KNOWLEDGE:	Synthesizes	Applies	Discusses	Defines the	Lacks	Not
Related to	broad textbook	expanded	basic	patient’s	knowledge to	observed
individual	mastery &/or	differential	differential	problems,	understand
patients	directed literature	diagnosis, can	diagnosis of	problem list	patient
	research, reads	discuss minor	active	needs	problems,
	extensively from	problems, reads	problems in	improvement.	obvious lack of
	many different	a good deal	own patients.	Apparent lack of	reading
	sources		Average reader	reading
DATA	Consistently	Utilizes,	Reviews	Recalls data as	Inaccurate,	Not
GATHERING:	synthesis, efficient,	detailed, broad-	basic history,	incomplete or	major	observed
Initial History/	and appreciates	based, obtains	accurate,	unfocused, and	omissions,
Interviewing	subtleties,	almost all	obtains most	missing,	inappropriate
Skills	insightful, assesses	relevant data	relevant data &	psychosocial	psychosocial
	all relevant data	including	most of the	components that	component
	including	psychical	psychosocial	are absent or	absent
	psychosocial		components	sketchy
DATA	Integrates subtle	Utilizes	Identifies	Assesses	Inaccurate,	Not
GATHERING:	findings of exam	organized,	major findings	incomplete data	major	observed
Physical Examination	in practice	focused, relevant findings	identified from data gathered	or unfocused, relevant data	omissions, inappropriate
Skill		of practice exam	in exam	missing,	psychosocial
				psychosocial	component
				components	absent
				absent or
				sketchy
DATA	Consistent	Assembles key	Report	Report poor	Inaccurate	Not
RECORDING/	recording of	information,	accurate,	flow in HPI,	data or major	observed
REPORTING:	concise, thorough	focuses,	complete	lacks listing	omissions
Writing	appraisal of	comprehensive	history and	detail or
Histories & Physicals	disease process & patient situation		physical	incomplete problem list
DATA	Synthesizes	Precise,	Reviews on-	Records but	Missing or	Not
RECORDING: Progress Notes	multidisciplinary data in notes	concise organized notes	going problems & team plan	needs organization,	inaccurate data	observed
				prioritizing
				relevant data

Area to be Evaluated	Outstanding	Above Average	Average	Needs Improvement	Unacceptable	Not Observed	Comments
DATA RECORDING: Oral Presentations	□Analyzes situation in a poised manner	□Discusses data in a fluent, focused manner	□Reports basic information, minimal use of notes	□Verbalizes data with major omissions, often relates irrelevant facts, rambling	□Repeatedly ill-prepared	□Not observed
DATA INTERPRE- TATIONS: Analysis	□Understands complex issues, interrelates patient problems	□Consistently formulates reasonable interpretation of data	□Constructs problem list, applies, reasonable differential diagnosis	□Frequently reports data without analysis	□Cannot interpret basic data	□Not observed
DATA INTERPRE- TATION: Judgement/ Management	□Manages patient soundly	□Consistently discusses diagnostic decisions	□Appropriately renders patient care, aware of own limitations	□Frequently reports data without analysis	□Cannot interpret basic data	□Not observed
CLINICAL PERFORM-ANCE: Outpatient Clinic	□Evaluates preventative care, good grasp of preventative health issues- development, education, anticipatory guidance	□Differentiates major issues, some fine points	□Recognizes major issues	□Deficient recall of major issues	□Inaccurate or major omissions	□Not observed
CLINICAL PERFORMANCE: History & Physical	□Accurate, assessment that is focused & detailed, at ease with all ages & illnesses	□Collects all pertinent data, comfortable with most patient & illnesses	□Reviews basic information, comfortable with most patients & illnesses	□Incomplete, unfocused, ill- at-ease with some patients or illnesses	□Major omissions, rude or unprofessional	□Not observed
CLINICAL PERFORMANCE: Patient Triage	□Accurately assesses patients’ level of acuity & prioritizes patients by degree of illness	□Formulates an accurate appraisal of acuity	□Can reliably distinguish between emergent and non-emergent patients	□Has difficulty recognizing emergently ill patients	□Unreliable or inconsistent judgement	□Not observed
PROCEDURES:	□Always performs proficiently & skillfully, very compassionate	□Consistently performs careful, confident, compassionate	□Performs reasonable skill in preparation & performance	□Awkwardly performs, reluctant to try even basic procedures	□No improvement even with coaching, insensitive	□Not observed
PATIENT EDUCATION & CARE: Reliability/ Commitment	□Initiates education & patient care, actively seeks responsibilities beyond assigned tasks	□Employs patient care, welcomes responsibility beyond assigned tasks at times	□Reports the time & energy required for education & patient care, fulfills responsibilities	□Repeatedly unprepared, appears lackadaisical in approach to education & patient care	□Unexplained absences, unreliable	□Not observed

Area to be Evaluated	Outstanding	Above Average	Average	Needs Improvement	Unacceptable	Not Observed	Comments
PROFESSIONAL ATTITUDES: Self- directed learning (knowledge & skill)	□Outstanding initiative, reads extensively, actively seeks education experiences beyond rounds & conferences	□Good insight, sets own goals, reads a good deal, participates in a few additional educational experiences, seeks feedback	□Reads appropriately, attends required rounds & conferences, appreciates feedback	□Frequent prompting required, seems to have a varied response to feedback	□Unwilling, lack of introspection, is not appreciative of all feedback	□Not observed
PROFESSIONAL DEMEANOR: Patient Interactions	□Preferred provider, consistently elicits & deals with patient’s emotional & personal problems in sensitive & skillful manner	□Gains confidences & trust, frequently elicits & deals with patient’s emotional & personal problems in a sensitive & skillful manner	□Empathetic, develops rapport, deals effectively with most of patient’s emotional & personal problems	□Occasionally insensitive, inattentive, frequently misses patient’s emotional &/or personal problems	□Avoids personal contact, tactless	□Not observed
PROFESSIONAL DEMEANOR: Response to stress	□Outstanding poise, selects constructive solutions	□Flexible, supportive	□Employs appropriate judgement	□Inflexible or loses composure easily	□Inappropriate response, inability to direct self or others	□Not observed
PROFESSIONAL DEMEANOR: Working Relationships	□Always establishes tone of mutual respect & dignity, makes a concerted effort to elicit & contribute to cooperation amongst health professionals	□Consistently has good rapport with other staff, makes attempts to elicit cooperation amongst health professionals, willingly contributes to the success of the team	□Cooperative, productive member of own team	□Lack of consideration for others	□Antagonistic or disruptive	□Not observed

Name of School	Major	Dates of Attendance	Year Graduated	Degree Earned

Quality	Seldom	Sometimes	Frequently	N/A	Comments
1) Is available to student.
2) Demonstrates understanding of the NP Role.
3) Utilizes student’s strengths and knowledge.
4) Role model for NP Practice.
5) Demonstrates effective rapport with clients.
6) Encourages student to assume increasing responsibility during experience.
7) Assists student in identifying goals and needs for experience.
8) Considers student’s limits according to status in program.
9) Provides immediate and adequate feedback with questions and patient presentations.

Statement	Yes	No	N/A	Comments
1) Is adequate space provided?
2) Is adequate time given to see clients?
3) Are there sufficient number of clients?
4) Are the types of clients varied as to age, type of problem, etc.?
5) Are students allowed to select clients according to their needs?
6) Are students given the opportunity to follow-up with clients and/or problems of interest?
7) Are reports from lab and x-ray accessible to students?
8) Is support staff appropriately helpful to students?
9) Is support staff accepting of student’s role?
10) Is philosophy of clinic to provide: a) health promotion and disease prevention? b) disease diagnosis and management? c) both?
11) Are instructional materials available for clients to supplement their learning (i.e., pamphlets, outside class opportunities, etc.)?
12) Are community resources, other agencies, and professional disciplines involved with client welfare?

Workshop/Course/Seminar	Date	Sponsoring Organization