STUDENT HEALTH RECORD

Transcription

1 STUDENT HEALTH RECORD ASSOCIATE DEGREE NURSING STUDENTS Welcome to Central Piedmont Community College! We are glad you have chosen CPCC to pursue your education in a health program. Submission of a Student Health Record is required by all students entering the Nursing Program. PLEASE NOTE: All records/reports must be verified with a healthcare provider s signature or stamp. The College has partnered with Castle Branch to maintain and track the A.D.N. Health Records, facilitate drug screens and conduct criminal background checks. Students must set up an account with Castle Branch. Select A.D.N. Program from the list of programs. The package cost is $97. Includes: Criminal background check Due: December 4 Drug screen Due: December 4 Immunization record tracking (Compliance tracker) Complete uploading of documentation by December 4 Submission of Health Record documentation Questions regarding uploading documentation: Questions concerning required health documentation: Upload the completed Health Record to your Castle Branch account on or before the December 4 due date. Contact Castle Branch Service Desk: Primary Contact person: Secondary contact person: Linda.porter@cpcc.edu Charlene.james@cpcc.edu Ext Location: Belk Bldg 1105C Location: Belk Bldg 1105B CRIMINAL BACKGROUND CHECK REQUIREMENTS PLEASE NOTE THAT ALL STUDENTS MUST COMPLETE A CRIMINAL BACKGROUND CHECK INSTRUCTIONS Cost If you have questions concerning this requirement PROGRAM ESSENTIAL FUNCTIONS/COMPETENCIES PROGRAM ESSENTIAL FUNCTIONS FORM Go to and select the A.D.N. Program from the list of programs. Follow instructions for setting up your account. The criminal background check is part of the $97 package for A.D.N. students. Contact the Medical Record Specialist for the A.D.N. Program. The Essentials form provides a list of competencies which students must be able to perform. The Essential Functions form (page 11) must be signed and uploaded to your Castle Branch account. 1

2 RE-ADMISSION TO ADN PROGRAM RE-ADMISSION REQUIREMENTS QUESTIONS A new physical examination form, drug screen, criminal background check and updated PPD are required when re-entering the Program if returning after 2 semesters. Consult the Medical Record Specialist for details when being re-admitted to the Nursing Program. HEALTH INSURANCE REQUIREMENT Due: December 4 Health insurance requirement Coverage Acceptable sources Not accepted as insurance PHYSICAL EXAMINATION PHYSICAL EXAMINATION HEARING AND COLOR VISION TESTS SIGNATURES/FACILITY STAMP DRUG SCREEN REQUIREMENTS Drug screen Requirements Required lab for testing: 12 panel Drug Screen will include: Positive drug screen due to prescribed medications Positive drug screen due to nonprescribed drugs All students must submit proof of health insurance coverage. Coverage must be in effect by the first day of class. Coverage must be maintained throughout enrollment in the Program. Students must update their health insurance information when the coverage changes and/or expires and is renewed. There is no minimum coverage amount required. There are many sources from which to obtain health insurance coverage. A few examples include: Medicaid, Affordable Care Healthcare.gov, Military insurance (Tri-Care), Blue cross Blue Shield, Aetna, Cigna, United Healthcare, etc. Sliding scale programs; Family Planning plans Only a physician, physician assistant or nurse practitioner shall perform the Physical Examination. Hearing and vision tests must be included as part of the Physical Examination. Vision test must include a color vision test. The Physical Examination and Immunization Record forms must include the healthcare provider s signature and the address/phone number or facility stamp. CPCC adheres to the policies and procedures of all clinical facilities with which the health programs are affiliated for student clinical learning experiences. These policies and procedures address the requirement for a drug screen and circumstances when policies are not followed. Nursing students must set up an account with Castle Branch. Follow the instructions to locate the specified Lab Corp locations for completing the drug test. Not all Lab Corp locations are participating with Castle Branch. A Registration form will be provided. Schedule an appointment and take this form and picture ID with you to the testing site. The charge for the drug screen is included in the package fee for Immunization Tracker for Nursing students. Amphetamines, Barbiturates, Benzodiazepine, Cannabinoid, Cocaine, Ecstasy (MDMA), Methadone, Methamphetamines, Opiates, Oxycodone, Phencyclidine (PCP), Propoxyphene A positive drug screen due to prescribed medications must be substantiated by documentation from the physician ordering the medications. A positive drug screen due to non-prescribed drugs will result in the student being ineligible to participate in a clinical experience. The student will be withdrawn from the program. 2

3 VACCINATION AND TITER REQUIREMENTS Students enrolled in the health programs may be at risk for exposure to serious, and sometimes deadly, diseases. If you work directly with patients or handle material that could spread infection, you should get appropriate vaccinations to reduce the chance that you will get or spread vaccinepreventable diseases. Protect yourself, your patients, and your family members. VACCINATION HISTORY (IMMUNIZATION/ VACCINATION RECORDS) Immunization Records may be obtained from any of the following sources: 1. High School Records: Your immunization records do not transfer automatically. You must request a copy. 2. Personal Shot Records-Must be verified by a doctor s stamp or signature, by a clinic or health department stamp. 3. Local Health Department 4. Military Records or WHO (World Health Organization) documents. 5. Previous College or University Your Immunization Records do not transfer automatically. You must request a copy. SPECIAL NOTE: *****Reports/documents specifying immunization or titer information must include the name of the healthcare facility providing the information. ************** YOU MAY USE ANY health care facility of your choice to obtain the required vaccinations/titers. NOTE: ***NOVANT URGENT CARE offers discounted rates for CPCC students at time of service. These rates do not apply if using insurance. Please see Novant Health Urgent Care information sheet distributed at A.D.N. Orientation for the discounted rates. SPECIAL NOTES FOR UPLOADING DOCUMENTATION TO CASTLE BRANCH: UPLOAD THE DOCUMENTATION UNDER EACH OF THE TITLED REQUIREMENTS. WHEN A SERIES OF VACCINATIONS IS NEEDED, YOU WILL UPLOAD THE FIRST VACC. DOCUMENTATION. EACH TIME A SUBEQUENT VACCINATION IN THE SERIES IS COMPLETED, YOU MUST UPLOAD THE PREVOUS VACCINATIONS AGAIN WITH THE CURRENT VACCINATION DOCUMENTATION. 3

4 SUMMARY OF REQUIRED VACCINATIONS/TITERS Tdap vaccination MMR vaccinations: Hepatitis B vacc./antibody titer: Varicella antibody titer: 2 Step PPD (TB skin test): Tdap vaccination within the past 10 years OR Tetanus/diphtheria vaccination and Pertussis titer (Negative titer: will need Tdap vacc.) Documentation of 2 MMR vaccinations OR Measles/mumps/rubella titers (blood test to prove immunity) Positive titer: Immune to MMR Negative titer: Non-immune- Must receive 1 MMR vaccination Documentation of 3 HepB vaccinations and HepB antibody titer Positive titer: Immune to HepB Negative titer: Start HepB vaccination series and repeat titer as scheduled If you have not received the HepB vacc., begin the vacc. series now. Upon completion of the series, a HepB antibody titer will be required. SPECIAL NOTE North Carolina State Law Section 15A NCAC 19A.0207 (Positive HIV and Hepatitis B Infected) This law addresses HIV and Hepatitis B infected Health Care Workers (THIS INCLUDES STUDENTS IN HEALTH PROGRAMS.) Excerpt: (b) All health care workers who perform surgical or obstetrical procedures or dental procedures and who know themselves to be infected with HIV or Hepatitis B shall notify the State Health Director...The notification shall be made in writing to the Chief, Communicable Disease Control Section, 1902 Mail Service Center, Raleigh, NC Where applicable: CPCC students are required to comply with this notification to the Chief, Communicable Disease Control Branch, Div. of Public 1902 Mail Service Center, Raleigh, NC Positive titer indicates immunity to Varicella (chickenpox) Negative titer indicates non-immunity: 2 vaccinations one month apart are required PPD#1 and PPD#2 completed 2-4 weeks apart OR Documentation of 2 PPDs within the past 12 months. OR QuantiFeron Gold blood test Positive PPD results: Chest x-ray is required SEASONAL INFLUENZA (Due in the Fall) If received BCG vaccination in the past: Chest x-ray documentation within past 5 years with current TB health screening required (Request form from Medical Record Specialist.) ANNUAL PPD (or TB screening if applicable): Due within 12 months The influenza vaccination is mandatory. (Religious/medical exemption forms are available.) Students will be denied clinical rotation if documentation is not provided prior to clinicals. Seasonal influenza vaccinations are available beginning in SEPTEMBER each year. To learn more about these diseases and the benefits and potential risks associated with the vaccines, read the Center for Disease Control and Prevention 4

5 DUE: December STUDENT HEALTH RECORD FOR A.D.N. PROGRAM PART I: AUTHORIZATIONS SECTION A: AUTHORIZATION FOR DISCLOSURE: CPCC INTERNAL RELEASE All medical records, physical examination results, reasonable accommodation request forms, or other medical information must be collected on separate forms, maintained in separate medical files kept apart from a student's general educational records, and treated as confidential in accordance with the Rehabilitation Act of 1973 and the Americans with Disabilities Act. As indicated by my signature below, I consent to disclosure of the medical, criminal background check and, if applicable, FBI information to administrators, Division Directors, Program Chairs, and other college officials involved in a request for reasonable accommodation or evaluation of qualifications for or performance in a course, program, service, activity or for purposes of implementing and enforcing necessary restrictions and accommodations; and for First Aid and safety personnel if a known disability may require emergency treatment. By signing below, I authorize Central Piedmont Community College and the Division to release and disclose any and/or all pertinent medical information as indicated in the above provision. I also authorize the release and disclosure of pertinent medical information by Central Piedmont Community College to the Division officials and/or Faculty who need to be aware of medical conditions that may require special needs. I understand that if I refuse to release my medical information to CPCC officials/faculty, I may lose my eligibility to continue as a student in CPCC's Health Programs. STUDENT SIGNATURE DATE STUDENT'S NAME PRINTED STUDENT ID NO. PROGRAM SECTION B: MEDICAL RECORDS RELEASE OF INFORMATION TO OFF-CAMPUS CLINICAL FACILITIES Off-campus clinical facilities may require medical information on students in programs with clinical assignments. Central Piedmont Community College is responsible for providing the clinical facility with medical data abstracted from the student s medical record. This data may include vaccinations received, medical test results and drug screen results. The facility may also require that the student provide a copy of their medical packet. By signing below, I authorize Central Piedmont Community College and the Division to release and disclose any and/or all pertinent medical information as indicated in the above provision, to an affiliating clinical facility which may require this information as a condition of my assignment to the facility. I understand that if I refuse to release my medical information to CPCC officials/clinical facilities, I may lose my eligibility to continue as a student in CPCC's Health Programs. I further understand that failure to release the records may result in the facility denying my clinical assignment. I also understand that I may not be able to fulfill the Program's graduation requirements. STUDENT SIGNATURE DATE STUDENT'S NAME PRINTED STUDENT ID NO. PROGRAM 5

6 CENTRAL PIEDMONT COMMUNITY COLLEGE SECTION C. HEPATITIS B VACCINATION ACCEPTANCE *****IF YOU HAVE COMPLETED THE HEPB SERIES PREVIOUSLY, CHECK THE APPROPRIATE HEPATITIS B VACCINATIONS completed: I completed the HepB vaccination series on (date), and will provide documentation to validate this. I completed the HepB Surface Antibody titer test on. (Submit titer lab report with immunization records.) I completed the HepB series and will now complete the HepB Surface Antibody titer test and submit a copy of the lab report. The HepB Antibody Titer is required. Student Signature Date Program Name *************************************************************************************************** ***** IF YOU HAVE NOT COMPLETED THE HEPB SERIES PREVIOUSLY, COMPLETE THIS SECTION: AGREE TO RECEIVE THE HEPATITIS B VACCINATION SERIES AND TITER 1. I, understand that due to my status as a student in a health program there is a high risk of occupational exposure to blood and/or other potentially infectious materials. I further understand that I am also at a greater risk of acquiring Hepatitis B virus (HBV) infection as the result of my exposure to blood and/or other potentially infectious materials. I have been informed about Hepatitis B and the Hepatitis B vaccine that is available. 2. I, agree to receive the Hepatitis B Vaccination series. I understand that this vaccination is a series of (3) doses administered in the following sequence: initial dose; second dose one month later; and the third dose administered six months from the first dose (or five months from the second dose). I understand that official documentation must be submitted immediately following the administration of each Hep. B vaccination.. I also understand that if I decide, at any time, to discontinue the vaccination series I must sign a declination form immediately. Furthermore, I understand that if the Hepatitis B vaccination becomes medically contraindicated (e.g. pregnant or have reaction to the vaccine) a Hepatitis B vaccination declination form must be signed. The declination form will be kept in the student s health records. 3. I, further understand that following the completion of the Hepatitis B vaccination series I must have a Hepatitis B surface antibody titer blood test performed two months from the completion date to verify immunity through vaccination. I also understand that a copy of the Hepatitis B titer test lab report must be submitted and will be placed in my medical records. Should the titer test be negative I understand I will be required to consuit with my physician to begin the HepB series again or receive a booster. I will then be required to repeat the HepB titer. I further understand that clinical facilities which require the Hep.B vaccination can refuse a student s clinical assignment to their facility. Should this occur, I further understand my standing in the Program could be jeopardized and Clinical/Graduation requirements may not be met. Student Signature Date Program Name Rev. 2/17 6

7 REPORT OF FAMILY AND PERSONAL MEDICAL HISTORY (Please type or print in black INK.) To be completed by student LAST NAME (print) FIRST NAME MIDDLE NAME *STUDENT ID NO. P ADDRESS CITY STATE ZIP AREA CODE/PHONE Cell phone number address DATE OF BIRTH (mo/day/yr) Last 4 digits of SS# GENDER M F PREVIOUSLY ENROLLED HERE YES NO IF YES, DATES/PROGRAM ATTACH Copy of Insurance card SEMESTER ENTERING (circle): FALL SUMMER 1 SUMMER 2 SPRING HOSPITAL/HEALTH INSURANCE (* NAME AND ADDRESS OF COMPANY) TELEPHONE (Number Of Insurance Company) NAME OF POLICY HOLDER *SOCIAL SECURITY NO. EMPLOYER IS THIS AN HMO/PPO/MANAGED CARE PLAN? YES NO POLICY OR CERTIFICATE NUMBER GROUP NUMBER NAME OF PERSON TO CONTACT IN CASE OF AN EMERGENCY RELATIONSHIP ADDRESS AREA CODE/PHONE The following health history is confidential, does not affect your admission status and, except in an emergency situation or by court order, will not be released without your written permission. Please attach additional sheets for any items that require fuller explanation. FAMILY & PERSONAL HEALTH HISTORY (Please type or print in black ink) To be completed by student Has any person, related by blood, had any of the following: Yes No Relationship Yes No Relationship Yes No Relationship High blood pressure Cholesterol or blood fat Cancer (type:) disorder Stroke Diabetes Alcohol/drug problems Heart attack before age 55 Glaucoma Psychiatric illness Blood or clotting disorder Suicide * HEIGHT * WEIGHT Have you ever had or have you now: (please check at right of each item and if yes, indicate year of first occurrence) Yes No Year Yes No Year Yes No Year Yes No Year High blood pressure Hay fever Jaundice or hepatitis Kidney stone Rheumatic fever Allergy injection therapy Rectal disease Protein or blood in urine Heart trouble Arthritis Severe or recurrent Hearing loss abdominal pain Pain or pressure in Concussion Hernia Sinusitis chest Shortness of breath Frequent or severe headache Easy fatigability Severe menstrual cramps Asthma Dizziness or fainting Anemia or Sickle Irregular periods spells Cell Anemia Pneumonia Severe head injury Eye trouble besides need glasses Sexually transmitted disease Chronic cough Paralysis Bone, joint, or other Blood transfusion deformity Head or neck radiation Disabling depression Knee problems Alcohol use treatments Tumor or cancer Excessive worry or Recurrent back pain Drug use (specify) anxiety Malaria Ulcer (duodenal or Neck injury Anorexia/Bulimia stomach) Thyroid trouble Intestinal trouble Back injury Smoke 1+ pack cigarettes/week Diabetes Pilonidal cyst Broken bones (specify) Regularly Exercise Serious skin disease Frequent vomiting Kidney infection Wear Seat Belt Mononucleosis Gall bladder trouble or gallstones Bladder infection Other (specify) Please list any drugs, medicines, birth control pills, vitamins and minerals (prescription and nonprescription) you use and indicate how often you use them. Name Use Dosage Name Use Dosage Name Use Dosage Name Use Dosage Name Use Dosage Name Use Dosage Revised lkp2/16 7

8 STUDENT NAME A.D.N PROGRAM PART II: FAMILY AND PERSONAL HEALTH HISTORY - CONTINUED (Please print in black ink) To be completed by student Check each item Yes or No. Every item checked Yes must be fully explained in the space on the right (or on an attached sheet). Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash hives, etc.) to any of the following? If yes, please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once. Adverse Reactions to: Yes No If Yes, Explanation With Type Of Reactions Required Penicillin Sulfa Other antibiotics (name) Aspirin Codeine or other pain relievers Other drugs, medicines, Chemicals, Latex (specify) Insect bites Food allergies (name) Do you have any conditions or disabilities that limit your physical activities? (if yes, please describe) Have you ever been a patient in any type of hospital? (Specify when, where, and why.) Has your academic career been interrupted due to physical or emotional problems?(please explain) Is there loss or seriously impaired function of any paired organs? (Please describe) Other than for a routine check-up, have you seen a physician or health-care professional in the past six months? (Please describe.) Have you ever had any serious illness or injuries other than those already noted? (Specify when and where and give details.) Yes No If Yes, Explanation and Dates Required IMPORTANT INFORMATION...PLEASE READ AND COMPLETE STATEMENT BY STUDENT (OR PARENT/GUARDIAN, IF STUDENT UNDER AGE 18): (A) I have personally supplied (reviewed) the above information and attest that it is true and complete to the best of my knowledge. I understand that the information is strictly confidential and will not be released to anyone without my written consent, unless otherwise permitted by Court order and/or law. (B) If I should be ill or injured or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from my medical record to a physician, hospital, or other medical professional involved in providing me (him/her) with emergency treatment and/or medical care. Signature of Student Signature of Parent/Guardian, if student under age 18 Date Date UPLOAD COPY OF HEALTH INSURANCE CARD UNDER THE HEALTH INSURANCE REQUIREMENT IN CASTLE BRANCH BY DECEMBER 4. 8

9 PARTIII: PHYSICAL EXAMINATION physician or clinic (Please print in black ink) To be completed and signed by (* )Must Be Completed.. * * * Last Name First Middle Date of Birth Student ID Number * * Permanent Address City State Zip code Area Code/Phone Number *Height *Weight *TPR / / *BP / *Vision: *Corrected Right 20/ Left 20/ *Uncorrected Right 20/ Left 20/ *Color Vision *Hearing: * (gross) Right _Left * 15 ft. Right Left Urinalysis: Sugar: Albumin Micro Hgb or Hct (if indicated) STS (if indicated)date Results 12 PANEL DRUG SCREEN To be completed ONLY through the lab specified by Certifiedbackground.com for Compliance Tracking. *Are there abnormalities? If so, describe fully Normal Abnormal DESCRIPTION (attach additional sheets) *1. Head, Ears, Nose, Throat *2. Eyes *3. Respiratory *4. Cardiovascular *5. Gastrointestinal *6. Hernia *7. Genitourinary *8. Musculoskeletal *9. Metabolic/Endocrine *10. Neuropsychiatric *11. Skin *12. Mammary *A. Is there loss or seriously impaired function of any paired organs? Yes No Explain *B. Is student under treatment for any medical or emotional condition? Yes No Explain *C. Recommendation for physical activity (physical education, intramurals, etc.) Unlimited Limited Explain *D. Is student physically and emotionally healthy? Yes No Explain * REQUIRED: HEALTH ASSESSMENT MUST BE COMPLETED BY THE MD, PAC, OR FNP DOING THE PHYSICAL EXAMINATION. Based on my assessment of this student s physical and emotional health on (date), he/she appears able to participate in the activities of a health professional in a clinical setting. Yes No If no, please explain: *Signature of Physician/Physician Assistant/Nurse Practitioner (Include Title) * Date *Print Name of Physician/Physician Assistant/Nurse Practitioner *Area Code/Phone Number *REQUIRED: Office Address OR FACILITY STAMP City State Zip Code Rev. 2/17lkp 9

10 STUDENT NAME Date of Birth PART IV: IMMUNIZATION RECORD Please print in black ink. To be completed and signed by physician or clinic. A complete immunization record from a physician or clinic should be attached to this form. SECTION A REQUIRED IMMUNIZATIONS DPT or Td (Must have total of 3) OR Tdap Td booster AND Pertussis titer Measles (2 MMR) (After first birthday) mo./day/year (#1) mo./day/ye (#2) mo./day/year (#3) Measles (after first birthday) (Disease date Not Accepted) mo./day/year (#4) ATTACH TITER LAB REPORTS Titer Date & Result Mumps (Disease date NOT Accepted Titer Date & Result Rubella (Disease date not accepted) Titer Date & Result NOTE: NEGATIVE MMR Titer RESULTS Requires 1 MMR vaccination SECTION B RECOMMENDED IMMUNIZATIONS (The following immunizations are recommended for all students and may be REQUIRED by certain colleges or departments) Hepatitis B Series REQUIRED for all Students In Health Programs at CPCC. HepB titer test required upon completion of series. NEGATIVE Titer RESULTS require 3 vaccinations and repeat titer Varicella IgG Titer Test REQUIRED for all students In Health Programs at CPCC. Varicella series of two doses REQUIRED if not immune to chicken pox *NEGATIVE TITER RESULTS: Require 2 vaccinations Date (#1) Date (#2) Date (#3) Date #1 or Bstr N/A Vacc.#1 REQUIRED By CPCC Date #2 Date #3 Date/results Attach lab report N/A Vacc.#2 (Disease date not accepted) ************** 2-STEP PPD is required PPD#1 Date PPD#1 Date Read and Results: HepB Surface Antibody titer Date/results ATTACH LAB REPORT Varicella IG titer ATTACH LAB REPORT No repeat titer is required PPD#2 Date PPD#2 Date Read and Results: Annual PPDs PPD Date PPD Date Read And Results PPD Date PPD Date Read and Results Chest x-ray required, if positive PPD or History of BCG vaccination TB Screening every 12 months after Chest x-ray CXR Date TB Screening Date CXR Results Results TB Screening Date Results SECTION C Other Immunizations Date rec d Seasonal Influenza Signature of Physician/Physician Assistant/Nurse Practitioner Print Name of Physician/Physician Assistant/Nurse Practitioner Date Phone Number REQUIRED: Office Address OR FACILITY STAMP City State Zip Code Rev. 2/17 lkp 10

11 CPCC Associate Degree Nursing Essential Functions Document Core Performance Standards for Admission and Progression The following are the non academic essential functions that must be mastered in order to complete and remain in the Associate Degree Nursing Program and become employable. They are provided here to help you assess the appropriateness of this career field for you. I. Cognitive/Critical Thinking A. Ability to measure, calculate, reason, analyze, integrate and synthesize information sufficient for clinical judgment. 1. Example: Apply information, evaluate the meaning of data and engage in critical thinking in the classroom and clinical setting. 2. Example: Identify cause-effect relationships in clinical situations. 3. Example: Concentrate to correctly perform nursing tasks within the scope of practice. 4. Example: Respond appropriately to constructive feedback. II. Communication A. Appropriate interpersonal interaction with other students, faculty, staff, patients, family and other professionals. 1. Example: Establish and maintain a professional relationship with patients and colleagues. 2. Example: Demonstrate appropriate impulse control and professional level of maturity. 3. Example: Effective communication with others, both verbally and in writing. 4. Example: Document and interpret nursing actions and patient responses in a clear, professional and timely manner. 5. Example: Listen and respond to others in an accepting and respectful manner. III. Motor Skills A. Sufficient motor function to execute movements required to perform general nursing duties. 1. Example: Participate, within reasonable limits, to safely maneuver equipment and patients to perform duties within scope of practice. 2. Example: Ability to administer cardiopulmonary resuscitation procedures. B. Sufficient physical endurance to participate fully in the clinical and academic settings at an appropriate level. 1. Example: Perform patient care that demonstrates the ability to lift and manipulate 50 pounds. 2. Example: Participate fully in required activities in clinical setting including extended periods of sitting, standing, lifting equipment and walking briskly as is reflective of the scope of practice in nursing. IV. Professional Conduct A. Function effectively and adapt to circumstances including highly stressful or rapidly changing situations. 1. Example: Examine and change his or her behavior when it interferes with professional relationships or the academic or health care environments. 2. Example: Maintain mature, sensitive and effective relationships with patients, colleagues, faculty, staff and other professionals. 3. Example: Demonstrate emotional stability to participate fully in the clinical and academic setting at an appropriate level. B. Incorporate professional standards of practice into all activities. 1. Example: Advocate, uphold and defend the individual s right to privacy and the doctrine of confidentiality in the use of information. 2. Example: Work effectively with a team in an academic or health care setting. 3. Example: Use correct and appropriate grammar in written and oral communication, always being culturally sensitive and professional. C. Demonstrate integrity and accountability in clinical and academic setting. 1. Example: Complete all assignments in a timely manner. 2. Example: Take all tests and final examinations on time as scheduled. D. Present self in a professional manner in clinical and academic settings. 1. Example: Attend clinical following the dress code policy, including appropriate hygiene with no detectable scents or odors. 2. Example: Wear appropriate clothing that is not distracting or offensive when in the learning environment. E. Utilize computers correctly, effectively and professionally to acquire information and to communicate with others. 1. Example: Use blackboard to collect course information. 2. Example: Utilize multiple computer systems to complete tasks. 3. Example: Utilize the internet to collect current information from appropriated sources to provide appropriate patient care. 4. Example: Communicate via e mail in a professional and ethical manner. V. Sensory A. Hearing sufficient to monitor and assess health needs. 1. Example: Able to hear monitor alarms, emergency signals, cried for help, and auscultatory sounds. B. Vision sufficient for assessment and observation necessary to perform nursing care. 1. Example: Observe patient responses, assessment data, patient medication and equipment. C. Tactile sufficient for physical assessment. 1. Example: perform palpation, functions of physical assessment and those related to therapeutic interventions (e.g.: insertion of a catheter. Student Signature: Date: Print Name: 11