Nurse Resident Evaluation of Secondary Preceptor
Full Name of Secondary Preceptor
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First Name
Last Name
Hospital Location
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Please Select
Ronald Reagan UCLA Medical Center
Santa Monica UCLA Medical Center and Orthopedic Hospital
Resnick UCLA Medical Center
RR Unit Where You Worked With Preceptor
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Please Select
4ICU (MICU)
5 East (OB)
5ICU (PICU-PEDS)
5 North (NICU)
5 West (PEDS)
6 East (Oncology)
6ICU (Neurotrauma ICU)
6 North (Neuro)
6 West (MED/SURG)
7E/5E (MS Geriatrics)
7ICU (Cardiothorasic)
7 North (CCU)
7 North (COU)
7 West (MED/SURG)
8 East (MED/SURG)
8ICU (Liver Transplant)
8 North (MED/SURG)
8 West (MED/SURG)
ED
OR
SM Unit Where You Worked With Preceptor
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Please Select
2MNP (Nursery)
2MNP (Post Partum)
2SWW (L&D)
2SWW (NICU)
3CW (PTU)
3NW (ORTHO)
3SWW (Overflow)
3SWW (PACU)
3SWW (PTU)
4CW (ICU)
4MNP (Medicine)
4NW (Med/Surg)
4SWW (Oncology)
5MNP (Intermediate Care)
5MNP (Monitor Tech)
5NW (Geriatrics)
6NW (Pediatrics)
ED (Nurses Station)
OR
NPH Unit Where You Worked With Preceptor
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Please Select
4 West Child/Adolescent
4 West Adolescent Eating Disorder
4 West Swing
4 East Adult Psych ICU
4 East Adult Substance Abuse
4 East Adult Acute
4 North Adult/Geriatric Psych
4 North Adult Eating Disorder
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Nurse Resident Evaluation of Secondary Preceptor
DIRECTIONS:
Please rate your secondary preceptor on the following items:
EXCEEDS
- Exceeded Expectations
MEETS
- Met Expectations
DOES NOT MEET
- Did Not Meet Expectations
N/A
- Not Applicable
ASSESSMENT
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Exceeds
Meets
Does Not Meet
N/A
Assessed and incorporated your learning style and preferences
Please provide an explanation for any areas marked "Does Not Meet" and/or provide any other comments regarding your experience:
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COMMUNICATION
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Exceeds
Meets
Does Not Meet
N/A
Communicated effectively with patients, families, staff, and physicians
Demonstrated communication practices to minimize risks associated with hand-off
Navigated and completed necessary documentation in the electronic medical record
Please provide an explanation for any areas marked "Does Not Meet" and/or provide any other comments regarding your experience:
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INTERPERSONAL
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Exceeds
Meets
Does Not Meet
N/A
Acknowledged strengths and weaknesses of others in an honest and respectful manner
Recognized and appreciated individuality of others
Reflected a positive attitude/desire to work with a new staff member
Provided patient centered care with sensitivity and respect for diversity of others
Please provide an explanation for any areas marked "Does Not Meet" and/or provide any other comments regarding your experience:
*
LEADER/INFLUENCER
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Exceeds
Meets
Does Not Meet
N/A
Demonstrated nursing expertise in the delivery of care through planning, delegating, and supervising others
Served as a role model for ethical and legal professional behaviors
Please provide an explanation for any areas marked "Does Not Meet" and/or provide any other comments regarding your experience:
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ROLE MODEL
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Exceeds
Meets
Does Not Meet
N/A
Used resources appropriately and efficiently (material and human)
Demonstrated a proactive response to anticipate patient needs during hourly rounding
Modeled professional development behaviors (life-long learner, specialty certified, member of a professional nursing organization)
Please provide an explanation for any areas marked "Does Not Meet" and/or provide any other comments regarding your experience:
*
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Nurse Resident Evaluation of Secondary Preceptor
FACILITATOR OF LEARNING
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Exceeds
Meets
Does Not Meet
N/A
Allowed independence appropriate for my knowledge and experience
Offered asistance and guidance when I needed it
Encouraged me to ask questions and speak up
Helped me to set and achieve goals based on my needs to meet orientation expectations
Incorporated clinical evidence to support teaching key concepts
Asked for my suggestions and comments and respected me as a peer
Created a safe and non-threatening environment
Prepared me for challenging situations, via the 9-step decision making process
Facilitated the development of critical thinking
Please provide an explanation for any areas marked "Does Not Meet" and/or provide any other comments regarding your experience:
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EVALUATOR
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Exceeds
Meets
Does Not Meet
N/A
Reviewed unit competency (required to meet) respective of my experience level (i.e., novice, advanced beginner, competent, proficient, expert)
Provided daily, consistent, and constructive feedback regarding my progress
Provided objective and clear feedback based on my actions and behavior
Please provide an explanation for any areas marked "Doe Not Meet" and/or provide any other comments regarding your experience:
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KNOWLEDGE INTEGRATION SKILLS
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Exceeds
Meets
Does Not Meet
N/A
Reviewed outcomes of nursing care (ie: nursing sensitive indicators, HCAHPS)
Demonstrated and evaluated Techback materials appropriate for the level of knowledge of patients and families
Sought out knowledge to address clinical questions
Used clinical evidence to make decisions and guide practice
Please provide an explanation for any areas marked "Does Not Meet" and/or provide any other comments regarding your experience:
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SOCIALIZER ADVOCATE
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Exceeds
Meets
Does Not Meet
N/A
Socialized me to the unit, staff, and physicians
Individualized my orientation based on my past experiences and identified needs
Please provide an explanation for any areas marked "Does Not Meet" and/or provide any other comments regarding your experience:
*
Any additional comments and/or suggestions:
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