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Clinical ski lls com petency
COMPETENCT Docu mentation
DEMONSTRATES: The ability to accurately record informationabout a patient in a timely manner
CRITERIAC:CompetentS=Requires SuperuisionD=Requires Development
PERFORMANCE CRITERIA (numbers indicate ANMC Nationa[Competency Standards for the Registered Af*rse, ?OO5)
C s D
1 ldentifies indications for docurnentation in the patient'schartlrecord {2.5. S.2i
2. Uses appropriate medical terminology and approvedabbreviation and acronyms ( l .1. 2.2, 2.6,4.2',
3- Content is relevant and accurate(r.2, 1.3, 2.?,2.5,2.6, 4.4,5.3, 6.1, r 0.2)
4. Adheres to legal requirements (l .1, 1.2)
5. Dernonstrates ability to effectively use the facilities' standardforms {1 .1, I.2, 10.2)
6. Demonstrates an ability to link theory to practice(3.2,4.1,4.21
*Source - Tollefson, J.2A12 "Clinical h/schomotor Skills Assessment Tools for5" Edition - CENGAGE Learning (pp66-68).
Nurses
Compulsory Reflection by Student: (Please refer to Levett-Jons and Burgeois text IlrE Clinicat Placement ppg+102 - model for reflection)
tra,t r^ii+{^ vaAicua &n<}t r.l4tu&r;tkd lo.{ ntxA,at...t . {, A.;A SPoC
on a separate sheet if nexssary
initia$How would you rate your overall performance whilst urdertaking this clinical activity? (Please
Unsatisfacto.y E Satisfaaory 1-l eood l_l Excellent GlComments by RN:
Canli*ue on a sheet if
How would you rate the overall performance of this student during this clinica[ activity? (prease in*iar) :
unsatisfactory I Satisfactory l-l cooc l-l Excetlent Wstudent Name: {fiease prrnfl RANSU 3H(ESTnAs;nn,
UNE - HSNS 206 Clinical Record Eook - Clinical Skiils Competencies - Revis€d Edition November 20 l 4 3l
Clinical skills com petencf/
COMPETENCY: Documentation
DEMONSTRATES: The ability to accurately record informationabout a patient in a timely manner
CRITERIA i,.
C=CompetentS=Requires SupervisionD=Requires Dev
PERFORMANCE CRITERIA {numbers indicate At'$lc NationalCompetency Sundards for the Registered Narse, 2fi)5)
C s D
I. ldentifies indications for documentation in the patient'schart/record (2.5, 9.2) t0
2. Uses appropriate medical terminology and approvedabbreviation and acronyms (1 -'l .2.2,2.6,4.21 AD
3. Content is relevant and accurate(1.2, I -3, 2.2, 2.5, 2.6, 4.4, 5.3, 6.1, 10,2) 60
4- Adheres to legal requirements (1 .1, 'l .2) 6fr
5- Demonstrates ability to effectively use the fucilities' stardardforms (1.1, 'l .2, 10.2)
4,0
6. Demonstrates an ability to link theory to practice(3.2, 4.1, 4.21
a0
"Source - Tollefton, J. 20I2 "Clini s Assessment Tools for Nurses56 Edition - CENGACE Learning (pp66-68).
COmpulSOry RefbCtiOn by StUdent: (Please refe to LevdtJones and Burg*is iext The C{mical Ptar,e,meltf ppw>*
I02 -modd for reflection)
N/w Lter^t-+'l^A ,,.Figrnt-e i1^ ;-ir.- "o tos
cl^N.t Iqr/- i& loalavrc* c.lnart
bcu.lPi iscisn 3lv t-a.j-Q ntanc-9^e* al$ta,vs
Cq*inue os a sepamte sheef rf necessary
How would you'rate;your ovsrall perfarmancewhilst undertaking IE clinical activity? (Please initiaD
Unqatisfactory [], satisfactory E eooo tl Excetlent EComments by RN:
Continae on a separate sfieef ff
Student Name: {pteaseprint} RftUf U Dae: 16/ov/tS
i44"a
, t( -aP. rfGlinical facilitator (RN): 6pease pna lisn: t'n
NB .Completion of this comped;rcy is refidired to satisfa€tolily complete this placement'
UNE - HSNS 263 Clinical Record Book - Clinical Skills Competencies - Revi:ed Edition March 2Ol 5
Clinical skills competency
CO MPETEN CY: Docu mentation
DEMONSTRATES: The ability to accurately record informationabout a patient in a timely mannerRN please place your initials in the appropriate column
CRITERIAC=CompetentS=Requires SuperuisionD=Requires Development
"Source - T 20I2 "Clinical nrnotor S ls Assessment Tools Nurses"
PERFORMANCE CRITERIA (numbers indicate ANMC NationalCampetency Standards for the Registered Narse, 2O05)
1. ldentifies indications for documentation in the patient'schart/record (2.5, 9.21
2. Uses appropriate medical terrninology and approvedabbreviation and acronyms (1.1. 2.2, ?.6, 4.2)
3. Content is relevant and accurate(l .2, 1 .3, 2.2,2.5,2.6, 4.4, s.3, 6.1, 't 0.2)
4. Adheres to legal requirements (l "1 , 'l .2)
5. Demonstrates ability to effectively use the facilities' standardforms {l .i, 1.2, 1 0.2)
6. Demonstrates an ability to link theory to practice{3.2, 4.1, 4.2)
5'fr Edition - CENCACE Learning (pp66-68).
Compulsory Reflection by Studentl (Please refer to Levett-Jones and Burgeois text Iire Clinica! Ptacemeni pp95102 - model for rdlection)
r"rt^l Lp- , [I,,Jr n"ts&;.^j-C i*q<-!qAe$ er"t'( v'\^4alz^-{,o{od<-ta 0ilte- be-0a*arr' c-t-tt
'rr"tX-O & t/-t' iAA r\t t^-t \tn "t-r.-s ,^ettCantinue an a sheet if
How would you rate your overall performance whilst undertaking this clinical activifif (Please initial)
unsatisfactory t satisfactory l*l Gooa l-l Excettent 1{2{l
Continue on a separafe sheef if necessary
How would you rate the overall performance of this student during this clinical activity? (Pte;lse initial)
] Exceltent WUnsatisfactory Satisfactory Good
Student Name: (ptease print) Rort.. SL.r.r'ta+t ,'.< Sign:
-Clinicalfacititator (RN): (prease ,,*, l, {€N}Aftfl/ sign=
Date:
oate:30'4'lSNB Completion of this competency is required to satisfactorily complete this placement.
UNE - HLTH 3i 0/5i0 Clinical Record Book - Clinical Skills Competencies - Revised EditionJune 20i 5 24
,(
COMPETENCY: Docu mentation
DEMONSTRATES: The ability to accuratelyabout a patient in a timely manner
record information
CRITERIA:C:CompetentS=Requires Su pervisionD=Req u ires Development
Clinical com pete ncy
, J, ools for Nursesran, E. 20.i6 "Clinical Pyschomotor Skills: Assessment6'i Edition - CaNCAGE Learning (pp88-9'I).
PERFORMANCI CRITERIA (numbers indicate ANMC NationalCampetency Standayds for the Registered Nurse,?AQS) fr)s D
I ldenlifies indications forchart/record (2.5, 9.2)
d0cum entation 1n the patient's /1 lul2. Uses appropriate medical terminology and approved
abbreviatlon and acronyms (.l.1. 2.2, 2.6, 4.2)
,ill Contenl is relevant and accurate
(1 2, 'i .3, 2.2,2.1,2.6, 4.4,5.3, 6.',t , '.i 0.2) I4. Adheres to legal requirements (l.,l, l.Z) A5. Demonstrates ability to effectively xse the facilities' standard
forms(l.l, i.2, I0.2) A6. Demonstrates an ability ro link theory to practice
(?) a1 d)\-),#.
i
-\nt T &H or6'al T
Compulsory Refleciion by Studeni: (Please referto LevetlJones and Burgeois text Ihe Ctinicat Placementppg}-'102 - model for reflection)
$tt. <r.-&i q,r.t*'s YO/'r.t
cAA-a, P
L (rl3eE ,*"r.-qd-i d,X kaArrrri
Continue on a separate sheef if necessary
you rate your overall p",fo*rrr"" *niirt
saiisfactory l--l Satisfactory l=_l
undertaking
Good
clinical activity? (Please initial)this
Comments by RN:
ki^-,,flv'a 6-..<--t+ /^ Jr-^4
'tg1'
A^-e- tv'-"2 ,
on a separate sheet if necessary
Student Name: {ptease print) furr"J * Shreatha.sign: 4Clinicat facilitator {*N}; lprease },r,, d; . laMr/ra t/ Sig;
ort", tvfov[16
Dal*: qfl&NB Completion of this competency is required to satisfactorirft complete this
UNE - HSNS 364 Clinical Record Book - Clinical Skills Competencies - Revised Edition January 2016
placement.
24
Clinical skills competency
COMPETENCY: Docu mentation
DEMONSTRATES: The ability to accurately record informationabout a patient in a timely mannerRN please place your initials in the appropriate column
CRITERIA:
C=CompetentS=Requires SupervisionD:Req u ires Deve lopment
PERFORMANCE CRITERIA(numbers indicate NMBA NationalCompetency Standards for the Registered Nurse)
C S D
I . ldentifies indications for documentation in the patient'schart/record (2.5,9.2)
,il./-tz/--
2. Uses appropriate medical terminology and approvedabbreviation and acronyms (l .1. 2.2, 2.6,4.2)
)-,/:r'= '
3. Provides relevant and accurate content(1.2, 1.3, 2.2, 2.5, 2.6, 4.4, 5.3, 6.1, 10.2)
/) .-/rt-'
t,// t'
4. Adheres to legal requirements (1 .l , I .2)/-,
.:'5. Demonstrates ability to effectively use the facilities' standard
forms (l .1, 1.2, 10.2)-:o,/-._
6. Demonstrates the ability to link theory to practice(3.2,4.1,4.2)
//- /,/,/ /
*Source - Tollefson. l, & Hillman, E. 2016 "Clinical Pyschomotor ls: Assessment Tools for Nurses6'h Edition - CENCACE Learning (pp88-91).
Compulsory Reflection by Student: (Please referto LevetLJones and Burgeois text The Clinical Placement-modelfor reflection)
'.f. -1 t{ r-t r tLf.1 c--rr,u( , '-t , 7 pr- cL ) c c rl'd,tk ( i.i a t <.lV.t.( <-, .t-
,r- ,1E-,:.r-.--.t'"',,.-(-ittfl-l r-1'.vr l- i.-lr-1 .i^!.C-t *,"vug-,".[-.",i ,.-t'(,!..r1 ,,'\-LL('
,L.I..\L.1]t'.,"-t,'G 'i. &...( r* f u.e .1 . ,r"-4tt'.1i.t i C-'L-,: 1-q,ttli.. o['r- 714::=tti,
,.r,Ual r t;r ,,-it.( i ,J ii^;t*! cif:'[:,i'LPl'-l,r-i-L . 'r.vt€:rf.rrzrt t-E-rr;-tiu'r--i{ctir c.'i,4
Ir* - ,.-;.1-i ( ,ri ,-;L, r..;1 itiiiion,u""b*:;'ri)Jrirn""""ru,y
How would you rate your overall performance whilst undertaking this clinical activity? (Please initial)
Unsatisfactory E satisfactory l-l cooo I-l Excetlent lT!
Comments by RN: f,J
- ({(, , )1,:') / "i ,/ ,. -1/1 I rl (i ,..J.1ct>t{ 7* ./t s
,l::, f I * r7/.2 (r,r.i( (/aJ-y /c /{(tfi
i,\ ,, ,/i'i !. {.,', /'
Continue on a separate sheet if nece
How would you rate the overall performance of this student during this clinical activity? (Please initial)i
Unsatisfactory E satisfactory l-l cooa @ Excellent l-lStudent Name: (ptease print) sisn, ;f-,:+#.'., pr1"' I ) /r q /rtClinical facilitator (RN): lprease
NB Completion of this competency is required to satisfactorily complete this placement.UNE -HSNS 368 Clinical Record Book - Clinical Skills Competencies - Revised EditionJune 2016
rJ -!:L^, it,.rt"i'."t
23
e0tilffTEltlfY: 3*el lnentati*n
recor* inf*rmati+r
e*a?=*,t.*C=C*rr*peaentS:iequires S*perui:ionD=Requiras ilev t
BEfttOl.lSTfA?€5: The *biliry tc accurategaba*t a p*tient in
= tirn*ly mailrer
fli-ira* :kill: eompetenry
Cliric*l &cilitatry {Rtl}: frmaserra* 9" $ig*:liB eamtrletian sf this .*r:rpete3ey i*-risrir;A rf ;Elsilcta
t!llLfitt
pERfO*i{ANet ea,fE$A {nua:bers indieate A!4t$ Na*anr,tC*y'**et**cy 5t*ndards {os, t*ze R*.gistered ##rse, 2€0S} { 5 il:. ldertifies i::dicarions for doEumentati+n *n :lte pati*.:t,r
ehart/reeor* i2.5, 9.:: ho2. lJ.:es *pgrcariate xedir=l terminolqy ara alpiaved
abbreviati*n a*d aer*r:pls {l.1. 2.!,'2.6, +.Zi 9o3. Cort€nt is relev*nt a*d aee$rate
{1,3, '1,3, 2"?,2,5,3,S, 4.4, 5.3, 5_t, }0,=} &D4" Adheres :a l*gal reqxirertent= {I "I, i.?} Lo5. femoRsrrales ablli:y to effeetively ure the faetlil!=' rtardard
lorms {1.:, L:, I *":} ,ry6. Demcnsara:es a* aliiitS:o linl al*€cry ac pra{tiee
(=-2, 4":, 4.:: &0J. ealZ *Clinical
fosehomotor Skills As es*msnt Tc*ls56 E*itisll - ff${A6f t*ar*tng {r*S6€8i.
C*rnprl**ry Refi*ctio* by $tudent {?kae e rdar *o t*vs*i-Jrrc* ar* *urg*ais texl I*e *ti:rr# F€*ee*: errt ??*-1E - :nod** for rellac:io*]
A .0,."d 614 0bs M e&i c*^,S3 r sv't :3 baJ,to,,rrix- drra],b C^A.L pLa'n CTu,aA LL.l-\k
rW)+X,vYaa e-rnelr"twr<t* Ot^$- tAtO].Jr^& CaJLz . I. UtJ-c.-A
C**ti*u* ** a sl*elrf r:e=ess*4r
l**$rwsuld y*u rate yoar *verall p*ri*ra*ncaxhil=t ur:de*aking !ili* eii*ieal a**uiq6 lpleaee iri**t;lJr:satlsfa*ary [} Safi*fa*tary []f eooC ffiJ Exeel**t fA
*qm.fi**ts by *l{:qg r r^.dt docurneA cat,on d*rl
C*rci
S*r*::sa a* a,=ep*ra{a sfieel ff *e+ss**ry
H*w stuld y*u r*la t** averall perf*nna**e *i !*is **u***t {uring thie *li*ical ad:v::y? {pE*= htral} :
unsatisfact*ry - Eati*fact*ry l]_} so* 17] Exccle* l,J$krd*ri ffarn*; {ptcaa*sriztt} (AN[9 €l_1LES1114 Sign:
U*E - Hst{l 2!€ fli:rieal Eectrd Eanir - f lixir:l tlcili< fnm**rnn.i5. - ea*;:*;r !**ia* arr,.-*i-* a*, ,
t , lbhzllt
-'1
