Performance appraisal form template



Self Performance Appraisal form: HCA Capital Division Perioperative Internship

Name:___Courtney Radford RN____________________________________________________

Date:_______________________________________________________

Appraiser: ___________________________________________________

Complete prior to 90 day and final evaluations to HCA Periop Clinical Educator

2 Discussion points

1. Has the first three months of the program good/bad/satisfactory or otherwise for you, and why?

2. What do you consider to be your most important achievements so far?

3. What do you like and dislike about working for this organisation/program?

4. What elements of your job do you find most difficult?

5. What elements of your job interest you the most, and least?

6. What do you consider to be your most important aims and tasks?

7. What action could be taken to improve your performance in your current position by you, and your boss?

8. List the objectives you set out to achieve in the next three months

|3 Score your own capability or knowledge in the following areas in terms of your current role requirements (0-1 Not applicable 2 poor, 3 | |

|satisfactory, 4 good, 5 excellent). Provide examples to support your assessment as needed. | |

| | |

|Applies basic fundamentals of perioperative nursing to subspecialties of surgery. | |

|Patient Safety | |

|Patient interview, consents, education, PNDS | |

|Asepsis and aseptic principles | |

|Surgical count | |

|Positioning and positioning equipment | |

|Preps | |

|Preference cards | |

|Anesthesia | |

|Medication | |

|Documentation | |

|Specimens | |

|Surgical attire and physical appearance | |

|Product and technical knowledge. Ability to problem solve and trouble shoot equipment, IT (Computer issues, electrocautery and other equipment) | |

|Resource management | |

|Reporting and administration | |

|Time management | |

|Delegation skills | |

|Adaptability, flexibility, mobility | |

|Leadership and integrity | |

|Team work, helping others/developing others | |

|Communication skills, hand offs | |

|Documentation | |

Comments:

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1 State your understanding of your main duties and responsibilities.

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