U-Mass Amherst, School Of Nursing, N498.498e Simulation Evaluation Form
Student:______Date: ______Evaluator:______Clinical Faculty:______
Objectives / Possible Points / Observed Patient ACHF hypertension / Observed Patient B
New Chest Pain / Actual
Points
Safety
*Hand Hygiene: Performs proper hand hygiene before caring for each patient and as needed / *2(1 each) / ___ Hand wash* / ___ Hand wash*
*Introduces Self: States name and role to patient, family member and/or helath care provider. / *2(0.5 each) / ___ Introduces Self*
___ Identifies Role * / ___ Introduces Self*
___ Identifies Role*
*Verifies Patient Identification: Ask patient to state their name, DOB and verify on ID Band.OR verify patient name and Medical Record Number on ID band. Must look at ID band to receive points / *2 (0.5 each) / ___ Verify Patient Full Name*
___ Verify Patient DOB* OR
____Verify MR# * / ___ Verify Patient Full Name*
___ Verify Patient DOB* OR
____Verify MR#*
*VerifiesAllergy: Asks the patient about allergies AND verifies correct allergy band. / *4 (1 each) / _____Ask about allergies*
_____Verify allergy band* / _____Ask about allergies*
_____Verify allergy band*
Communication: Explains to patient/and or family member what they are doing and/or why. / 4 (1 each) / ___ Explain Assessment
___ Explain Interventions / ___ Explain Assessment
___ Explain Interventions
Error: Identifies medical error/s and states correction for error. / 3 (1 each) / ___ O2 off / ___ Allergy Bracelet off
____Identify MD order route for Morphine wrong
Assessments and Critical Thinking
Identifies the Priority Patient / 2 / __Priority Patient to assess first when going in room initially because Airway
ABC’s LOC: Assesses Patient’s Airway (able to speak), Breathing (chest rising and falling), Circulation (check pulses) and Level of Conscious-ness (Should state out loud assessing these areas) / 4(0.5 each) / __ Airway
__ Breathing (check)
__ Circulation (check)
__ LOC / __ Airway
__ Breathing (check)
__ Circulation (check)
__ LOC
Vital Signs /O2 Sat/Pain: Assesses initial and previous VS/O2 Sat (don’t need to actually do, can check monitor) and Pain 0-10 (PQRSTU). Identifies pt’s normal and/or abnormal as a scenario evolves. / 4(0.5 each) / __ Temp, BP, HR, RR ↑
__ O2 sat
__ Pain 0-10 (PQRSTU)
__ Identifies changes / __ Temp, BP, HR, RR
__ O2 sat
__ Pain 0-10 (PQRSTU)
__ Identifies changes
Focus Assessment: Assesses systems appropriately based on patient presentation, signs and symptoms. / 5 (0.5 each)
/ ___ LS Crackles
___ Pedal Edema
___ Dyspnea (ask about shortness of breath) / Chest Pain Assessment
____When it started?
____Location? ____Radiation?
_____Quality? ____Pain Scale 0-10
____Elevated ST segment____Oxy Sat lower
Problem Identification and Critical Thinking
Identify Problem/s: Identifies actual and/or possible medical and/or nursing problems (Can identify while thinking out loud or by actions) / 2(0.5 each) / ___ Potential fluid overload 600 in 200 out (in report)
___ Anxiety related to shortness of breath
______/ ___ Actual MI
___ Allergy to shellfish – problem with order for Cardiac Cath with dye
______
Interventions, Evaluation & Critical Thinking
Priority Interventions: Initiates appropriate priority interventions in a timely manner for each patient. / 8.5
(0.5 each)
/ ___ Raise the HOB
___ Apply O2
___ Reassure & support
___ Reassess VS as needed / ___ Raise HOB ___ Apply O2
____Get EKG ___ Give NTG
___ Assess VS before each NTG dose
___ Call MD
After Call MD do or say what would do:
___Increase Oxygen(First unless delegating)
____Morphine (*with correct dose calculated- critical to pass)(Second)
___ ASA ____Hang NS 40 mL
____Delegate blood work____Cancel stress test
____ Reassess VS as needed
Delegates appropriate possible tasks to others. / 2.5
(0.5 each) / ___ Check O2 sat as follow-up
___ Provide care / ___ EKG ___ Blood work
____Cancel Stress Test
Communicates with HCP in timely manner: Gives appropriate info using SBARRguidelines (see sheet near phone to call HCP if needed). / 2 (0.5 each) / ___ Situation ___ Background
___ Assessment/ Recommendations
___ Read Back
Other Critical Thinking and Processing Components
Thinking Process: Discusses out loud during/after scenario possible problems, pathophysiology, and/or rationale for assessment and interventions. / 1 (0.5 each) / _____Thinks out loud during scenario
1 ______10
rarely all times / _____Thinks out loud during scenario
1 ______10
rarely all times
Reflection: Identifies strengths and areas for improvement when viewing video with objectives and discussion with faculty and peers. / 2 (0.5 each) / ___Strengths
___Areas of Improvement / ___Strengths
___Areas of Improvement
Final Actual Total Points: _____
Equivalent Letter Grade: _____
Remediation and Redo Recommended: Yes No
Comments (write in colums to right): / 50 possible total points
Grading Scale
Actual Points (out of possible 50) / Equivalent Letter Grade / CET Behavior Rating46.5-50 (equivalent to 93-100) / A / 4.0
45-46 (equivalent to 90-92) / A- / 3.7
43.5-44.5 (equivalent to 87-89) / B+ / 3.3
41.5-43 (equivalent to 83-86) / B / 3.0
40-41 (equivalent to 80-82) / B- / 2.7
38.5-39.5 (equivalent to 77-79) / C+ / 2.3
36.5-38 (equivalent to 73-76) / C / 2.0
36 or lower (equivalent to 72 or lower) / C- or lower / 0 and scenario must be repeated
Special Note: Any * items are critical to do to pass
Last revised 0.3.01.11 mah/mec/el, kad
Toolinitially developedby of U-Mass School of Nursing Faculty, University of Massachusetts, Amherst, MA, USA. Please do not use without permission.Contact person Helene Cunningham