Shenandoah University



Shenandoah University Division of Physical Therapy

Clinical Practicum (Circle one) I II III Evaluation

Student Name _____________________________________ Clinical Instructor________________________________________________________

Facility Name ___________________________________________________________ Date ________________

To the Clinical Instructor:

This evaluation form is based on specific course objectives, and was designed to provide meaningful feedback to your student on his/her clinical performance. The student is under the Direct Personal Supervision of a Physical Therapist. Direct Personal Supervision – The physical therapist is physically present and immediately able to direct and supervise tasks throughout the time these tasks are performed. Telecommunications does not meet the requirements of Direct Personal Supervision.

At midterm and final, please review this evaluation with the student to identify areas of strength and weakness. Specific comments about the student’s performance in each area are required if the student’s performance is not satisfactory. No box should be left unmarked. The pass/fail grade is determined by the DCE and is not related to quantity of areas that needs improvement, but rather the quality of the student performance, consistency, amount of supervision, and adherence to all safety criteria.

The ORIGINAL evaluation form should be returned with the student.

Definitions below apply to each criteria based on the student’s CURRENT place in the program,

NOT where he/she will be at the end of the final clinical practicum.

The Elements of Patient/Client Management: include Examination, Evaluation, Diagnosis, Prognosis, Interventions (Plan of Care), Outcomes. (The Guide to PT Practice, APTA, 1997) Clinical Reasoning and implementation of Evidence-Based Practice are additional components of Patient/Client management.

Unacceptable (UA): Does not meet expectations for this clinical setting based on current level in the PT program. The student needs continuous verbal cueing and/or continuous physical assistance from the CI. Substandard in this component of Patient/Client Management. There is potential for patient injury. The student takes minimal or no initiative.

Needs Improvement (NI): Needs improvement for this clinical setting based on current level in the PT program. The student inconsistently demonstrates this behavior. The student needs cueing and assistance from the CI in this component of Patient/Client management. There is potential for patient injury. Beginning to demonstrate the ability to carry-over knowledge and skills to novel situations.

Satisfactory (Sat): Meets expectations for this clinical setting based on current level in the PT program. Acceptable Patient/Client Management for current level in the program. Student actively minimizes potential for patient injury. The student needs guidance/advice from the CI to expand knowledge or skills. The student demonstrates progressive applications of knowledge, skills and behaviors. The student consistently demonstrates this behavior.

Exceeds Expectations (EE): Exceeds expectations for this clinical setting based on current level in the PT program. The student confers with the CI prior to or following an activity for the purpose of sharing information and/or validating decision-making. Exceptional Patient/Client Management. The student is capable of functioning safely, with mentoring, in this behavior. The student consistently demonstrates this behavior.

N/O or N/A: Not observed or not applicable.

Grading Policy

A grade of Pass, Incomplete, or Fail can be awarded for each Practicum. The grade is determined by the DCE with input from the CI and CCCE and when necessary, the SU PT faculty. The pass/fail grade is not related to quantity of areas that need improvement but rather the quality and consistency of the student performance, amount of supervision, complexity of tasks as appropriate for student level, and adherence to all safety criteria.

Behavioral Criteria for CP I:

At this level, the student is sharing the caseload of the CI. The student requires complete supervision for 75% of the case load. The student is able to contribute 25% to all aspects of care: Examination, Evaluation, Diagnosis, Prognosis, and Interventions. The student is not expected to be independent in any aspect of patient/client management. All Professional Behaviors at the Developing-Level are required. The student is expected to discuss current evidence and best-practice standards. Safety, in actions and thought, is a critical component of this clinical experience.

Behavioral Criteria for CP II:

At this level, the student is sharing the caseload of the CI. The student requires complete supervision for 50% of the case load. The student is able to contribute 50% to all aspects of care: Examination, Evaluation, Diagnosis, Prognosis, Interventions, and Discharge. The student is not expected to be independent in any aspect of patient/client management. All Professional Behaviors at the Developing-Level are required. The student is expected to share current evidence and best practice standards. Safety, in actions and thought, and acceptable interpersonal skills are critical components of this clinical experience.

Behavioral Criteria for CP III:

At this level, the student is sharing the caseload of the CI. The student requires complete supervision for 25% of the case load. The student is able to contribute 75% to all aspects of care: Examination, Evaluation, Diagnosis, Prognosis, Interventions, Discharge, and Outcomes. The student is not expected to be independent in any aspect of patient/client management. All Professional Behaviors at Entry-Level are required. The student is expected to implement current evidence and best practice standards. Safety, in actions and thought, acceptable interpersonal skills, and evidence of clinical reasoning are critical components of this clinical experience.

|I. Professional Behaviors , Core Values |Mid Term | Final |

|The Student will: | | |

| |UA |

|II. Safety |Mid Term |Final |

|The Student will: | | |

| |UA |

|III. Interpersonal Relations & Communications Skills |Mid Term |Final |

|Under direct personal supervision the student will: | | |

| |UA |

|IV. Problem Solving |Mid Term |Final |

|Under direct personal supervision the student will: | | |

| |UA |

|V. Documentation |Mid Term |Final |

|Under direct personal supervision the student will: | | |

| |UA |

|VI. Basic Clinical Skills |Mid Term |Final |

|Under direct personal supervision the student will: | | |

| |UA |

|Overall Midterm Comments: (Please make a copy of this page to give to the student, or fax. Please do not remove the mid-term from this packet. Thank you!) |

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|Areas of Strength: |

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|Areas of Improvement: |

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|Midterm Progress Report |

|Reviewed with the student progress to date at (name of facility ) ________________________ |

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|CI Name (print _______________________ |Student Name (print) ________________________________ |

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|__________________________________ |__________________________________ |

|CI signature & date |Student signature & date |

Please, FAX 540-665-5530, or bring in a copy of this page to Missy Wolff-Burke at Mid-term

|Overall Final Comments |

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|Areas of Strength: |

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|Areas of Improvement: |

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|FINAL Progress Report |

|Reviewed with the student progress to date. |

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|__________________________________ |__________________________________ |

|CI signature & date |Student signature & date |

Please return this entire document, and the rest of the evaluative materials to SU Division of Physical Therapy at Final.

Please keep a copy for your records. The student needs to retain the originals.

Feb 2013

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Student name: ___________________________________

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