DIALYSIS
I understand the importance of preserving the confidential nature of the information of Total Renal Care, Inc. (“TRC”). This includes, but is not limited to, TRC’s data and records relative to business interests, computer systems and programs, projections, business plans, inventions, trade secrets, know-how, as well as information wherein TRC has an obligation of confidentiality to a third party and information concerning any patient, employee, physician, independent contractor, student, fellow or volunteer. I understand the necessity that such information not be compromised for any reason other than necessary business or medical communications and treatment needs.
I further understand that patient information is confidential and not to be discussed with or disseminated to anyone, either inside or outside the company, except on an as-needed basis for the treatment of the individual, payment related thereto, or for TRC’s healthcare operations in compliance with federal and state regulations. Unauthorized dissemination may be a violation of federal and state laws.
I am also aware and fully understand, that any violation of this Confidentiality Agreement is grounds for corrective action, up to and including immediate termination of employment or termination of any employment related contract or agreement between TRC and any of its subsidiaries and/or related organizations by which I am bound.
Print Name__________________________________ _________________
Signature ___________ _________________
Company Name ___________
Date ________________________________________
Affiliation TRC Employee____ Student____ Agency Employee____
Volunteer____ Independent Contractor____ Attending Physician____
Medical Director____ Nephrology Fellow____
ACKNOWLEDGEMENT OF RECEIPT OF ALCOHOL/ DRUG POLICY
AND AGREEMENT TO ABIDE BY THE POLICY
I, ___________________________(print name) hereby acknowledge that I have received a copy of CSI’s HSHS Department Alcohol/Drug Policy for the Clinical/Practicum Site (referred to hereafter as the Policy) and acknowledge the following:
I have read the Policy and have had the opportunity to ask questions about the Policy and the consequences for violating any terms of the Policy.
I understand that my compliance with all terms of the Policy is a condition of my remaining in the HSHS Department Program, and I agree to abide by all terms of the Policy.
I authorize the lab and/or Medical Review Officer or designee retained by CSI to release test result information to the HSHS Dean or his/her designee.
________________________________ _________________________
Student’s Signature Date
________________________________ _________________________
Parent’s Signature if student is under 18 Date
WITNESSED BY:
COLLEGE OF SOUTHERN IDAHO HSHS DEPARTMENT REPRESENTATIVE
By________________________________ Date_________________________
CLINICAL EVALUATION
The documentation of a student's clinical behaviors will be a summative evaluation completed at the end of each clinical rotation. This evaluation process will be completed by both the instructor and the student. If there are significant differences between the student and faculty evaluations, an attempt to compromise will be made, but the faculty's evaluation will stand. The clinical component of ADN education is designed to allow you, the student, to measure and achieve the level of competence necessary to meet the level and terminal objectives of the program and to be successful in your endeavors. This will require that you make yourself aware of the clinical requirements for each semester and implement behaviors which allow you to achieve these requirements.
The evaluation tool uses a "satisfactory/unsatisfactory" rating scale. To provide consistency among faculty and students, the identification of each factor in the rating scale is as follows:
U Unsafe performance
Inaccurately performs
S Able to perform:
a. Identification of the patient/client.
b. Communicates with patient/client about and/or during the care being demonstrated.
c. Demonstrates procedure/knowledge accurately.
d. Completes within a reasonable time frame.
e. Cleans up appropriately.
f. Documents and reports appropriately.
g. Maintains role of AD student nurse.
Successful completion of a semester requires the student achieve a satisfactory for each clinical behavior. Once an identified clinical behavior has been demonstrated and evaluated at a satisfactory level, it is expected that this behavior will continue in succeeding semesters at a satisfactory level. Should the student regress below satisfactory, a deficiency notice will be issued and a mutual plan made between the student and instructor to remedy the regression before the end of the semester. Deficiencies noted during the semester require a written plan of action be developed by the student and approved by the faculty member evaluating the student at that time. It is the responsibility of the student to share this written plan with the next clinical instructor. (See policy in ADN Student Handbook).
College of Southern Idaho Student Name_______________________
Associate Degree Nursing Program Clinical Instructor____________________________
Clinical Evaluation Tool – NURR 201 Semester: _______________________________________
Clinical Site: ____________________________________
Wellness-Illness: Applies knowledge of position on wellness-illness continuum and utilizes the nursing process to problem solve, think critically, and make clinical judgments.
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Level/Program Objectives
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Unsatisfactory
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Satisfactory
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Comments:
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III. Assessment
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Performs a comprehensive nursing assessment through analysis of GFHP assessment data, physical assessment data, lab and other diagnostic data
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Evaluates for changes in health status and begins to identify complex needs
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Integrates the impact of developmental, emotional, cultural, religious, and spiritual influences on health status
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Assesses for changes in health status and identifies appropriate actions
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Analyzes patient’s response to interventions
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Assess discharge needs and ability to access community resources
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Evaluates patient’s response to medications
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Recognizes trends in lab data and takes appropriate nursing action
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VI. Teaching-Learning
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Assesses patient/support person(s) learning ability, barriers, motivation to learn, and learning needs prior to teaching-learning
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Implements steps in the teaching process in increasingly complex patients.
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Participates in meeting goals toward discharge planning
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Implements and evaluates teaching to patient’s identified at risk for complications
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IV. Clinical Decision-Making
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Integrates the steps of the nursing process, evidence-based practice, and critical thinking in patient care
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Identifies pathophysiology of the medical surgical patient and relates to patient situation
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Integrates evidence-based practice, collected through technological resources and other modalities, in decision-making.
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With assistance, utilizes nursing process and critical thinking to prioritize and organize care for one or more patients
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Follows existing care plan to provide for continuity of care
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Seeks guidance in evaluation of care regimen outcomes
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With supervision, provides safe, evidence-based care.
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Caring: Integrates caring in the development of dynamic interpersonal relationships and implementation of nursing actions.
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Level/Program Objectives
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Unsatisfactory
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Satisfactory
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Comments:
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II. Communication
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Integrates cultural sensitivity throughout the nursing process
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Utilizes appropriate communication channels to report relevant assessment data
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Communicates relevant and complex information in a concise and clear manner to clients and healthcare team members
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Reports medication side effects or medication inaccuracies to appropriate member of the health care team and instructor in a timely manner
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Establishes therapeutic communication with patients
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Utilizes verbal and nonverbal communication skills while establishing caring relationships
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Demonstrates intermediate computer literacy related to patient care.
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V. Caring Interventions
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Demonstrates with minimal supervision the ability to perform procedures/skills based on facility guidelines
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Establishes and maintains caring relationships with patients/support person(s).
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Safely administers medication with minimal supervision
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Evaluates patient response to medications
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Maintains human dignity
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Provides developmentally appropriate nursing care
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Evaluates for physiological & psychological safety of patients
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Functions as a patient advocate
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Implements complex nursing interventions based upon patient assessment
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Unique Individual: Values unique aspects of all individuals, including self, and utilizes this awareness in all interactions within the healthcare environment.
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Level/Program Objectives
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Unsatisfactory
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Satisfactory
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Comments:
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I. Professional Behavior
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Accepts ethical/legal responsibility for own actions as expressed in ANA Code of Nursing
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Demonstrates self reflection by:
Examining own ideas, feelings, and behaviors
Recognizing and accepting learning potentials and limitations
Evaluating own performance in a structured journal
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Accepts responsibility for nursing care given by self
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Maintains confidentiality of all healthcare information
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Functions, with minimal supervision, in the role of a professional nurse as a member of the healthcare team.
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Accurately documents nursing cares and procedures
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Utilizes self-reflection for continued growth in nursing practice.
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Demonstrates personal responsibility by:
Arriving on time
Informing both school and agency of absence/tardiness
Adhering to school and agency dress code
Following Student Handbook guidelines
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Demonstrates honesty in:
Documentation
Performance of skills (meds, treatments, etc.)
Interaction with others
Clinical paperwork
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VII. Collaboration
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Identifies and recognizes roles and responsibilities of members of the health care team and collaborates with the team effectively
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Collaborates with patient/family in setting goals and evaluation
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VIII. Managing Care
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Provides evidence-based, cost effective patient care
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Utilizes appropriate technology in provision of care
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Recognizes aspects of safe/unsafe environment
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Provides patient-centered nursing care
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Demonstrates beginning level of patient management, leadership, and organizational skills by: appropriate delegation, accepting responsibility and accountability for own actions, accepting accountability and responsibility for delegated nursing actions.
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With supervision, accepts legal/ethical responsibility for nursing care. Follows agency policy and procedures, functions within legal scope of a nursing student, shares pertinent information with agency staff and instructor
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Promotes the rehabilitation potential of the patient
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Maintains environment that supports patient independence
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Additional Comments:
I have reviewed the contents of this evaluation and fully understand its implications.
Student Signature: _______________________________________________________________ Date____________________
Clinical Instructor Signature: _______________________________________________________ Date____________________
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