Clinical Skills Self-Assessment Form.

PRAC 6665/6675 Clinical Skills 

Self-Assessment Form

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Summary of strengths:

Opportunities for growth:

Now, write three to four (3–4) possible goals and objectives for this practicum experience. Ensure that they follow the SMART Strategy, as described in the Learning Resources.Clinical Skills Self-Assessment Form. 

Master of Science in Nursing  

Practicum Experience Plan

Overview:

Your Practicum experience includes working in a clinical setting that will help you gain the knowledge and skills needed as an advanced practice nurse. In your practicum experience, you will develop a practicum plan that sets forth objectives to frame and guide your practicum experience.Clinical Skills Self-Assessment Form.

As part of your Practicum Experience Plan, you will not only plan for your learning in your practicum experience but also work through various patient visits with focused notes as well as one (1) journal entry.

Complete each section below.

Part 1: Quarter/Term/Year and Contact Information

Section A

Quarter/Term/Year:

Student Contact Information

Name:

Street Address:

City, State, Zip:

Home Phone:

Work Phone:

Cell Phone:

Fax:

E-mail:

Preceptor Contact Information

Name:

Organization:

Street Address:

City, State, Zip:

Work Phone:

Cell Phone:

Fax:

Professional/Work E-mail:

Part 2: Individualized Practicum Learning Objectives

Refer to the instructions in Week 2 to create individualized practicum learning objectives that meet the requirements for this course. These objectives should be aligned specifically to your Practicum experience. Your objectives should address your self-assessment of the skills found in the “PMHNP Clinical Skills Self-Assessment Form” you completed in Week 1.Clinical Skills Self-Assessment Form.

As you develop your individualized practicum learning objective, be sure to write them using the SMART format. Use the resources found in Week 2 to guide your development. Once you review your resources, continue and complete the following. Note: Please make sure each of your objectives are connected to your self-assessment. Also, consider that you will need to demonstrate how you are advancing your knowledge in the clinical specialty.Clinical Skills Self-Assessment Form.

Objective 1: <write your objective here> ( Note : this objective should relate to a specific skill you would like to improve from your self-assessment)

Planned Activities:

Mode of Assessment: (Note: Verification will be documented in Meditrek)

PRAC Course Outcome(s) Addressed:

· (for example) Develop professional plans in advanced nursing practice for the practicum experience

· (for example) Assess advanced practice nursing skills for strengths and opportunities

Objective 2: <write your objective here> ( Note : this objective should relate to a specific skill you would like to improve from your self-assessment)

Planned Activities:

Mode of Assessment: (Note: Verification will be documented in Meditrek)

PRAC Course Outcome(s) Addressed:

·

Objective 3: <write your objective here> ( Note : this objective should relate to a specific skill you would like to improve from your self-assessment)Clinical Skills Self-Assessment Form.

Planned Activities:

Mode of Assessment: (Note: Verification will be documented in Meditrek)

PRAC Course Outcome(s) Addressed:

·

Part 3: Projected Timeline/Schedule

Estimate how many hours you expect to work on your Practicum each week. *Note: All of your hours and activities must be supervised by your Preceptor and completed onsite. Your Preceptor will approve all hours, but your activities will be approved by both your Preceptor and Instructor. Any changes to this plan must be approved.Clinical Skills Self-Assessment Form.

This timeline is intended as a planning tool; your actual schedule may differ from the projections you are making now.

I intend to complete the 144 or 160 Practicum hours (as applicable) according to the following timeline/schedule. I also understand that I must see at least 80 patients during my practicum experience. I understand that I may not complete my practicum hours sooner than 8 weeks. I understand I may not be in the practicum setting longer than 8 hours per day unless pre-approved by my faculty.

Part 4 – Signatures

Student Signature (electronic): Date:

Practicum Faculty Signature (electronic)**: Date:

** Faculty signature signifies approval of Practicum Experience Plan (PEP)

Submit your Practicum Experience Plan on or before Day 7 of Week 2 for faculty review and approval.

Once approved, you will receive a copy of the PEP for your records. You must share an approved copy with your Preceptor. The Preceptor is not required to sign this form.Clinical Skills Self-Assessment Form.