Preceptor Weekly Review of Student 

Tri County Tech 

Division of Practical Nursing

As educators, we value your input regarding how the students implement care and how they present themselves in your environment. This form is not intended to grade the student but rather an opportunity for you to share what you observed while they were assigned to work with you.

The following indicators are examples of the behavior we, as a faculty, would expect of the student.  Please share any positive experiences and concerns regarding your assigned student in the space provided.

Sign in to Google to save your progress. Learn more
Email *
Please fill in your full name *
Please fill in the student's name *
Please type in the dates of the week this evaluation is being submitted. *
1. PROFESSIONALISM:

+ Consistently dressed appropriately

+ Appears rested and energetic

+ Punctual on and off duty

+ Demonstrates adaptability, displays a positive attitude, adapts quickly to change, performs well under pressure

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment
 *
Required

2. SAFE PRACTICE:  

+Demonstrates proficiency with nursing skills and utilizes sound judgment essential in reaching reasonable decisions  

+Utilizes appropriate safety measures during patient care

+Seeks assistance when the situation encountered is beyond the students’ knowledge and experience

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment 

 *
Required

3. COMMUNICATION:  

+ Clear and accurate in conveying information to others 

+ Provides ongoing feedback regarding patient’s condition to primary nurse

+ Listens attentively to others with courtesy and consideration

+ Documentation is clear, concise, and well organized with correct spelling

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment 

 *
Required

4. ASSESSMENT:  

+ Accurately assesses basic physical, emotional, spiritual, and socio-cultural needs of patients

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment 

 *
Required

5. PLANNING:  

+ Implements critical thinking in analyzing data

+ Establishes goals and prioritizes problems/tasks 

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment 

 *
Required
6. IMPLEMENTATION:

+ Provides safe and effective nursing care, responding promptly and appropriately to patient’s needs and changes in the patient's condition

+ Problem solves efficiently using a Nursing Process approach

+ Manages time effectively

+ Meets daily objectives in patient care

+ Provides appropriate patient teaching based on patient needs and knowledge level

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment
*
Required
7. EVALUATION:

+ Exhibits accountability in the evaluation of nursing care

+ Modifies nursing approach appropriately based on evaluation

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment

*
Required
8. ACCOUNTABILITY:

+ Demonstrates initiative in seeking relevant knowledge, asking pertinent questions, and seeking advanced information in patient care

+ Accepts responsibility for own actions

+ Serves as a positive role model by displaying and encouraging teamwork and cooperation

+ Treats others fairly and impartially with dignity, being respectful of cultural differences

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment 
 *
Required
9. PHARMACOLOGY:

+ Safely and effectively administers medications according to the five rights

+ Demonstrates initiative in researching unknown medications

+ Initiates and maintains intravenous therapy utilizing the appropriate technique

+ Monitors fluid and electrolyte balance effectively

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment
*
Required
10. LEADERSHIP:

+ Demonstrates the ability to provide appropriate care to multiple patients with a variety of needs

+ Leads by establishing and communicating clear direction, goals, and priorities

+ Establishes a positive rapport with team members

+ Independently fulfills the responsibility and role of the LPN

Please select only one of the ratings, and then in the "other" box - feel free to leave a comment
*
Required
11.  Does the student meet your overall expectation of a Graduate Practical Nurse? *
12.  Would you recommend this student for employment as a Practical Nurse?
 *
13.   Did the student approach you in a professional manner when arranging their preceptorship hours?
 *
14.    Would you consider being a preceptor again?
 *
What suggestions do you have for improvement of the preceptor program? *
Please indicate the number of hours completed by the student nurse this week. (Remembering there is a minimum of 120 spanning a 6 week period. ) *
By typing your name here you're signing electronically that the information above is accurate. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Tri County Technology Center.

Does this form look suspicious? Report

Google Forms