Management of Health and Illness in Adults. The clinical semester for this course will run from August 22 until December 2, 2016.

Course Number & Title Course Credit Hours Semester Length NUPR 541: Nurse Practitioner Practicum III: Management of Health and Illness in Adults 5 Semester Hours (225 clinical clock hours) The clinical semester for this course will run from August 22 until December 2, 2016. Failure to complete the total number of required clinical hours within that time will result in a failing course grade. Course Faculty Chicago Acute Care Melissa Carlucci, MS, APN, ACNP-BC mcarlu2@uic.edu 312-413-0054 Amy Morgan, MS, APN, ACNP-BC amorga7@uic.edu Sarah Fitz, MSN, APN, ACNP-BC safitz@uic.edu Alicia Maloney, MS, APN, ANP-BC arusse6@uic.edu Rockford Rich McLaughlin, MS, APN, ACNP-BC Rhamcmc@uic.edu 815-395-5624 Quad Cities Dr. Alyssa Wislander, DNP, APN, ACNP-BC, CPNP-BC awisla2@uic.edu 309-757-9467 ext. 26 Peoria Dr. Susan Copp, Ed.D, MS, APN scopp2@uic.edu 309-671-3411 Urbana Patricia Reichard MSN, APN, FNP-BC reichard@illinoi.edu 217-244-4385 1

Adult-Gerontology Acute Care Nurse Practitioner Clinical Practicum Welcome to NUPR 541! This 5 credit semester-hour practicum will allow you to build on the clinical skills from NUPR 539/540 and further develop evidence-based clinical practice. Practicum Description Each practicum in the AGACNP program curriculum is a 5 Semester Credit Hour/225 clock hour clinical course designed to provide opportunities for you to develop your clinical skills and integrate them with the theoretical and scientific underpinnings for effective primary care or acute care practice. The practicum emphasizes evidence-based clinical practice in the management of common and complex health problems. Students will utilize concepts acquired in prior core courses to conduct comprehensive and episodic history and physical exams, and use the data gathered to form a differential diagnosis and management plan. It also encompasses the realms of health promotion, anticipatory guidance, disease prevention, and management of acute and chronic disease across the adult lifespan. Overall Practicum Objectives The focus of the AGACNP student is to provide patient-centered quality care to the adult and older adult populations. The student applies evidence in practice designed to improve quality of care and health outcomes under the guided supervision of faculty and clinical preceptors. 1. Accurately assess the health status of patients with common health problems. 2. Develop a diagnosis of patient health status. 3. Develop a plan of care. 4. Evaluate responses to treatment and modify treatment plans. 5. Demonstrate a personal, collegial, and collaborative approach to patient care. 6. Implement a teaching/coaching component to patient care. 7. Demonstrate professionalism in an advanced practice role. 8. Monitor the quality of health care practice. 9. Provide culturally competent care. 10. Utilize evidenced-based approaches to improve outcomes. 2

ACUTE CARE TRACK: Course Evaluation Criteria Evaluation Graded by Percent of Grade Clinical Evaluation Tool (mid-point & final 20% each) Clinical Preceptor 40% Simulation H&P Note Clinical Instructor 15% Clinical Case Presentation Clinical Instructor 15% Standardized Patient SOAP Note Clinical Instructor 15% Faculty Communication (60%)/Professionalism (40%) Clinical Instructor 15% Standardized Patient Encounter Clinical Instructor P/F Simulation Patient Encounter Clinical Instructor P/F Typhon Practice Profile Clinical Instructor P/F Typhon Data Checklist Clinical Instructor P/F Self-Reflection Assignment Clinical Instructor P/F Board Exam Readiness Test Clinical Instructor P/F P/F = Pass/Fail Grading Scale Cumulative Percentage Practicum Grade 90-100% A 80-89% B 70-79% C 60-69% D <60% F Students must earn a minimum grade of B to pass the practicum courses. Failure to do so will require you to retake the course. All assignment and final course scores are calculated to the number 2 places to the right of the decimal point (for example, 85.25%). For further information, please see the information on practicum policies in the UIC CON student handbook. Late Assignments All late assignments that are a percentage of the course grade will be penalized with a 5% deduction from the assignment grade for each day that it is late. For pass/fail assignments, 5% will be deducted from the final course grade for any assignment that is submitted late. Standards of Practice The professional competencies used as resources for course content include the Advanced 3

Practice Nursing Core Curriculum of The Essentials of Master s Education for Advanced Practice Nursing (AACN, 1996), the Criteria for Evaluation of Nurse Practitioner Programs (NTF, 2012), the National Organization of Nurse Practitioner Faculties (NONPF) Nurse Practitioner Core Competencies (2011; amended 2012), and the National Organization of Nurse Practitioner Faculties (NONPF) Population-Focused Nurse Practitioner Competencies (2010, 2012). Practicum Policies Please see the College of Nursing Student Handbook at http://www.nursing.uic.edu/sites/default/files/2015-16_uic_con_student_handbook.pdf Academic Dishonesty Please see the UIC graduate student handbook for specific policies related to academic dishonesty. In brief, the following (although not a complete list) constitutes academic dishonesty: giving or receiving any information regarding standardized patient or simulation cases (including via social media and other forms of electronic communication), fabrication or plagiarism in any form (including power point slides for the student case presentation). If academic dishonesty is suspected, the assignment will receive a grade of 0 and there will not be an opportunity to resubmit the assignment. Attendance Policies Students must complete their clinical clock hours at the clinical site as assigned by course faculty. Students are not permitted to change their clinical site assignments. Attendance at ALL scheduled clinical days is expected. If you must be absent, notify your preceptor and clinical instructor immediately and arrange to make up the time. Attendance at ALL scheduled student workshops and on-campus activities is mandatory. Failure to attend a required on-campus day, including but not limited to simulation, standardized patient encounter, case presentation, and all student workshops, will result in a 5% deduction from the final course grade. Incomplete Grades A practicum grade of incomplete will be given only in extreme circumstances. All assignments, including those given a pass/fail grade, must be completed for the student to be given a passing grade for this course. If a student receives an Incomplete grade in a practicum course, they will not be permitted to progress to the next practicum course in the program until the Incomplete grade is converted to a final course grade of A or B. Practicum Performance Any student who demonstrates unsafe or ineffective advanced nursing practice may be dismissed from the practicum at any time. Unsafe or ineffective practice is any behavior determined by faculty or preceptor to be actually or potentially detrimental to the patient or health care agency. Additionally, students may be removed from the practicum for any unprofessional behavior, lack of preparation for clinical, deficits in problem-solving skills, or if it is determined that they are not meeting the required NONPF competencies. Any behavior evaluated as unsafe/unprofessional will result in removal from the clinical site until a remediation plan is developed. If any behavior is evaluated as unsafe/unprofessional on the final evaluation the student will receive a non-passing grade. 4

Disabilities The Office of Disability Services works to ensure the accessibility of UIC programs, classes, and services to students with documented disabilities, including vision or hearing impairments and emotional or physical disabilities. Students with disability/access needs or questions may contact the Office of Disability Services at 312-413-2183 (voice) or 312-957-4822 (TTY only) or visit: http://www.uic.edu/depts/oaa/disability_resources/index.html. HIPAA Requirements The federal government's Privacy Rule became effective April 14, 2003. The Privacy Rule provides the first comprehensive federal protection for the privacy of health information. The College initiated the following course requirements to ensure privacy compliance for all CON students: 1. You will be required to sign a confidentiality statement before you access any patient information (paper, electronic and oral), and your instructor will keep copies on file. 2. You will be required to keep all patient information confidential. 3. Patient information is reviewed only in private areas (i.e., not in elevator or cafeteria). 4. You will not be allowed to take any patient information that is identifiable from the hospital/clinic. 5. You are not to access a patient chart or other protected information outside of your clinical rotation area, e.g. from your home computer. 6. You will be required to follow all hospital/clinic policies and procedures for patient privacy at your site of clinical placement. Failure to protect patient health information is considered a federal offense, and failure to comply with this College requirement may result in failure of the practicum course and possible disciplinary action including dismissal from the University. Practicum Overview This course has a competency-based clinical curriculum designed to assist you to develop and apply the knowledge, skills, and attitudes you will need to successfully transition into the nurse practitioner role. Approximately 2-3 days per week will be needed to fulfill the 225 practice hours required for the practicum. For the fall 2016 semester, clinical hours must be completed between August 22 and December 2, 2016. The required credentials for each clinical will vary by clinical site and must be completed prior to beginning the practicum. Information regarding requirements for you to fulfill is available on Blackboard, with additional information available from your clinical instructor. So as to NOT be delayed in your practicum site, you must promptly adhere to satisfying its requirements. You cannot begin your practicum rotation until you have met all credentialing requirements for the assigned site. Additionally, the Castle Branch system must be kept current, and any past due requirements will result in removal from the clinical until all requirements are met. Clinical Resource: All students are required to have the Up-to-date app (downloaded through the UIC library website) on their mobile device as a resource for clinical. **Note: Students are expected to use personal phones for accessing clinical applications and resources only. Any texting while at the clinical site is considered unprofessional behavior. 5

Documentation of Clinical Hours: You will be seeing approximately 4-6 patients in a clinical day, depending on the site and acuity of the patients (i.e., AGACNP students in ICU rotations may only see 1-2 patients per day). Each patient assessment must be presented to your preceptor, and then final assessments and all clinical decisions are to be made under the guided supervision of your preceptor. Individual patient encounters, in addition to the amount of time spent at the clinical site, must also be accounted for in the NPST system (see below). There will be a deduction of 10% from the final course grade if the NPST system encounter log does not accurately reflect the number of actual patient encounters and/or the NPST system time log does not accurately reflect time spent at the clinical site over the course of the practicum. NPST time and case logs; Student schedule The Typhon Nurse Practitioner Student Tracking System (NPST) is used to log data from all patient encounters and document clinical hours during the practicum courses. At the end of the day, you are expected to enter encounter data directly online via the Typhon/NPST site. NPST technical support includes online tutorials and student FAQs that are available on the NPST website. Refer to these first if questions arise about how to enter and upload your encounter data. NOTE: You will have a maximum of 2 weeks in which you are able to enter your case log and time log records. If hours are not documented within that time period, you may lose credit for those hours and will need to repeat them in order to complete the required clinical hours. Please note: Any falsification of a case log record or clinical hours is considered to be a violation of academic integrity and disciplinary action will be taken. As a student in this course, you are expected to keep your schedule current and accurate in the NPST student scheduling system so that your clinical instructor can plan site visits and track your clinical hours. Selected procedures and skills for acute care practice are listed in Appendix A. As you perform these procedures during clinical rotations, document the date in the NPST system using the appropriate CPT code (or in the clinical notes section if there is no procedure code). Share your log information with your clinical preceptor so they can assist with planning your clinical rotation experiences. Entering of Clinical Site Schedule Your clinical site schedule must be entered a minimum of four weeks ahead into the NPST database. Students are expected to communicate with their assigned faculty member immediately via email if there is any reason that you will not be at a site as scheduled and the reason. It is your responsibility to keep your database updated and communicate with your faculty instructor immediately if you are experiencing any issues with your clinical site assignment or preceptor. Clinical groups All students are assigned to a campus-specific clinical group. Each group will be assigned a clinical instructor, who will act as your faculty supervisor and main contact person for the clinical and all other required course assignments. Clinical Instructor Site Visit During the semester your clinical instructor will arrange a visit to your practicum site to meet with your preceptor. Your clinical instructor may also observe one or more clinical encounters. The purpose of this ungraded evaluation is to assess your clinical progress, provide feedback, and confirm that you are meeting expectations for safe practice and developing the AGACNP 6

competencies. For the vast majority of our students, the clinical instructor site visit is an opportunity for mentoring and to build collaborations with you and your preceptor. However, a remediation plan will be developed and further site visits scheduled if it is determined that expectations are not being met. You must demonstrate that you are meeting these expectations in order to pass the practicum. Your clinical instructor will also maintain regular contact with your clinical preceptors throughout the semester to discuss any clinical practicum issues at their discretion and/or by request. Following this site visit, your clinical instructor will discuss your clinical progress with you. Additional Requirements The following are additional requirements for AGACNP students: 1. All AGACNP students are required to maintain a current ACLS certification throughout the practicum courses. A copy of your ACLS card must be submitted to your clinical instructor prior to starting clinical. 2. All AGACNP students are required to attend the Fundamentals of Critical Care Support course offered by the Society of Critical Care Medicine at one time point during the clinical courses. This course is offered twice per year in Chicago; however, you may also choose to attend at an alternate location (see the Society of Critical Care Medicine website for more details). The hours from this course will be applied to one of your clinical courses, as determined by the program director. A copy of the certificate from the course must be submitted to your clinical instructor to verify your attendance. 3. All AGACNP students are required to complete two practice tests in preparation for the board certification exam. Practicum Evaluation Methods 1. Faculty Communication (60%)/Student Professionalism (40%) Faculty Communication 1. Students must engage in weekly email communication with your clinical instructor to update them on your clinical activities (see rubric below) and address any questions or concerns. 2. Professional communication includes but is not limited to responding to email from any faculty member within 1 business day and using appropriate and formal communication (email, texting, etc.) with faculty & preceptors. Faculty communication grades will be assigned at the discretion of the clinical instructor, taking into account the rubric below and all professional communication standards. There will be 60 points allocated for faculty communication. Student Professionalism includes but is not limited to: 1. Seeking and accepting feedback in order to continually improve the educational experience, knowledge, and clinical skills. 2. Demonstrating appropriate demeanor, language, appearance, and behavior in the classroom and in the clinical setting. 3. Being considerate and respectful of others (preceptors, peers, patients and faculty) 7

time, rights, values, religious, ethnic and socioeconomic backgrounds, lifestyles, opinions, and choices. 4. Recognizing limitations and seek help when your expertise, knowledge, or level of experience is inadequate to handle a situation in the classroom or clinical setting. 5. Use of cellular phones for restricted to clinical applications and resources only; not for personal text communication, etc. when in the clinical and classroom environments. Professionalism grades will be assigned at the discretion of the clinical instructor, taking into account both clinical and classroom behavior. There will be 40 points allocated for professional behavior. The following information must be included in your weekly check-in emails: 1) How many patients did you see and what was your role in the assessment and management of these patients? Did you present these patients and to whom? How many notes did you write and what type? Provide a brief synopsis of the patients in which you held a primary role. 2) What reading did you complete outside of clinical this week? What did you learn this week about (1) patient management and (2) the NP role or other professional issues? 3) Self-Evaluation: How do you feel you are doing in clinical? What things are you doing well and what things do you need to work on? What feedback have you received from your preceptor? 4) Did you meet your goals for this week? If not, what will you do to work toward meeting them in the future? What are your goals for next week (be specific)? How many hours have you completed thus far? 2. Clinical Preceptor Evaluations Each of your preceptors will complete the "UIC Student Competency Clinical Evaluation Form" at the midpoint and end of each clinical rotation to evaluate your progress (Appendix D). It is your responsibility to provide your preceptors with the evaluation form and to ensure that the completed evaluation is returned to your clinical instructor by the dates specified on the course calendar. Failure to submit evaluations may result in a grade of 0 for the evaluation and/or an incomplete for the course. Evaluations must be submitted in either a pdf or Word format. Jpeg files will not be accepted. Scoring for this evaluation is explained with the Evaluation Form. The scoring is weighted so that a straight 2.0 average equals 85%. On any single item, a 1 indicates that performance is below basic expectations for a student at this level, and is thus an area for you to focus on for improvement. A 3 indicates an area where performance is above basic expectations for a student at this level, and thus is an area where you have been doing exceptionally well. Our expectation is that most students will average at least 2 or above on their clinical preceptor evaluations. Please note: final clinical evaluation grades are assigned by faculty with preceptor input. It is the responsibility of the student to ensure that midpoint and final clinical evaluations are 8

submitted by the due date on the course calendar. Late evaluation forms will be penalized with a 5% deduction from the evaluation grade for every business day that the form is submitted after the due date. 3. Standardized Patient Encounter An on-campus observed clinical encounter using a standardized patient will be used as a clinical performance evaluation. All standardized patient encounters will take place at your regional campus. The evaluation will be conducted using a trained patient and will be observed and graded by your clinical instructor. This is an opportunity for you to demonstrate interview and physical exam skills and clinical decision-making in a controlled environment. More information about the standardized patient encounter will be made available prior to the encounter date. A SOAP note from the encounter will be submitted via SafeAssign and graded by your clinical instructor. The grading rubric for this assignment will be posted on the course Blackboard site prior to the encounter. 4. Lab Simulation An on-campus observed clinical encounter using a high fidelity simulator will be used as a clinical performance evaluation. All simulation experiences will take place at your regional campus. The simulation lab is a learning environment that allows you to practice your clinical assessment and decision-making skills. A debriefing session will be held following the simulation to review the case, discuss appropriate management, and receive feedback from faculty. More information about the simulation experience will be made available prior to the scheduled date. An H&P note from the encounter will be submitted via SafeAssign and graded according to the rubric provided. 5. Student Clinical Case Presentation Clinical case presentations will be held according to the course schedule during the semester in your clinical group. This is a 20-minute case presentation from each student based on an actual patient from the current practicum site. The purpose of this presentation of relevant clinical topics is designed to foster development of professional presentation skills and present an evidence-based patient case as a learning opportunity for your student colleagues. With assistance from your preceptor, students will choose one of their clinical patient encounters to develop the presentation according to the assignment rubric. A list of scholarly references used to prepare the presentation must be included. This is to be a PowerPoint presentation. The presentation, including your scholarly references, must be emailed to your clinical instructor within 24 hours of the scheduled class meeting. See Appendix B for the clinical case presentation grading rubric. The clinical instructor will evaluate your presentation and provide feedback. 6. NPST Data Quality Checklist; Practice Profile These logs form the basis for your developing practice profile and will be a key part of your professional portfolio. The NPST system must be accurately completed and 225 total hours logged for completion of this practicum. NPST data quality is determined by a number of factors, including the following: Completeness of patient case logs Completeness of student time logs Completeness of student clinical schedule 9

Timeliness of data entry 100% accuracy in reflecting all clinical time and activities 6a. NPST Data Quality Checklist NPST data quality will be evaluated by faculty at the end of each semester; however, it is your responsibility to monitor your data quality regularly. Important: Be sure to enter your data in timely fashion, as it is set for access to a maximum of two weeks post your clinical day. Any further delay and you risk losing your ability to post your past clinical hours and cases. Students will complete the NPST/Typhon Data Quality Checklist (Appendix C) and submit via SafeAssign by December 2, 2016. 6b. Practice Profile The practice profile is the Case Log Totals (Graphical) report from your NPST data and provides a visual representation of your clinical experiences for the current semester. Filter the report so that it represents the cases solely for the current semester. Students will submit their practice profile via SafeAssign by December 2, 2016. 7. Self-reflection Toward the end of each semester, students complete a self-reflection assignment for the purpose of validating progress. The goal for this activity is to engage you in considering how your clinical abilities and professional growth are changing. You will submit this assignment via SafeAssign by November 18, 2016. The self-reflection documents your developing competencies as an AGACNP in relation to the NONPF professional standards for nurse practitioner practice. AGACNP competencies are available at http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/adultgeroaccompsfinal2012.pdf This is a written assignment divided into 2 parts. (1) Use your current practice profile (from the NPST system; See above) to write a narrative about your practice so far. Discuss how you have progressed throughout the practicum, what goals you have achieved and/or are still working toward, and your overall thoughts about the clinical. (2) Choose 2 of the NONPF competencies (see above) and describe either (a) how you have met them or (b) how you plan to work toward meeting them in the future. Provide specific examples from your clinical rotation as support. 10

Appendix A: Selected Procedures and Skills for Acute Care Below is a list of common activities, assessments, skills and procedures performed by Adult-Gerontology Acute Care Nurse Practitioners. You should be seeking out opportunities to participate in these activities during your clinical rotations. Share this list with your preceptors so they can assist with planning your clinical experiences. As you perform these activities during clinical, document the date in the Typhon Nurse Practitioner Student Tracking System. Daily Activities/Assessments General Skills/Consults Perform Comprehensive History & Physical Exam (inpatient & clinic) Perform Focused History & Physical Exam (inpatient & clinic) Perform a Consult Call a Consult Participate in Rounds Present Assigned Patients (during rounds, to preceptor, MD, etc.) Focused Assessments (i.e., heart and lungs sounds, neurological exam, GI exam) Management/Plan of Care Formulate working and differential diagnoses/prioritize diagnoses Develop plan of care/revise plan of care based on new and ongoing data Select, interpret and supervise diagnostic tests, procedures and plan of care that contribute to working and differential diagnoses Follow up with consulting service recommendations Collaborate with interdisciplinary team, patient and family members Perform discharge teaching Arrange follow up appointments Note Writing & Documentation History and Physical Exam Daily Progress Note - SOAP Note Consult Note Discharge Instructions/Summary Clinic Note Procedure Note Document assessment and diagnostic criteria that supports working and differential diagnoses in the plan of care Medication Management Perform thorough medication history Select new medications based on diagnoses, guidelines and patient history Use electronic device/program to look up drugs, dosing, drug interactions, side effects, special considerations Consider organ (kidney, liver) function when selecting/dosing medications Perform teaching for new medications Laboratory monitoring for drugs Antibiotic management/guidelines 11

Skills ECG Interpretation Chest X-Ray Interpretation Abdominal X-Ray Interpretation CT Interpretation (head, chest, abdomen) ABG Analysis Spirometry Interpretation Hemodynamic Monitoring (ICU) Common Laboratory Tests to Interpret CBC with differential Chemistry Panel Liver Function Tests Urinalysis Amylase/Lipase Troponin, CPK, BNP, Cholesterol Panel Thyroid Panel Ventilator Management (ICU) ESR, Lactate Non-Invasive Ventilation Glucose, A1C (CPAP/BiPAP) Calculations (ie: Cr Clearance, Anion Microbiology - blood culture, fungal Gap, FENa, corrected Ca, risk culture, urine culture, respiratory scores) viral panel Procedures (if you get the opportunity to watch, assist or perform) Arterial Blood Gas Central Venous Line Insertion and Removal Chest Tube Insertion/Removal Arterial Line Insertion/Removal Thoracentesis Paracentesis Endotracheal Intubation Suturing Abscess I&D Defibrillation/Cardioversion Wound Debridement Local Anesthesia Application 12

Appendix B: Clinical Case Presentation Rubric Student Name: Course: Criteria Points Possible Points Earned Presentation of the History and Physical Exam 1. CC, HPI 6. Physical exam by system 2. PMH, PSH 3. Allergies, Medications 4. Family History, Social History 5. ROS List of Early Differential Diagnosis Based on H&P 1. Must include 5 diagnoses Presentation of Diagnostic Testing and Findings 1. Appropriate laboratory studies with interpretation 2. Appropriate imaging studies with interpretation (include images) Differential Diagnosis 1. List of revised differential diagnoses Must include 3 diagnoses 2. Discussion of how each diagnosis in the revised list was ruled in or ruled out 3. Final diagnosis with supporting evidence 10 5 10 10 Presentation of the Management Plan 1. Must be evidence-based approach 2. Recent research studies and clinical practice guidelines must be included as supporting evidence 15 Evidence-based Practice Discussion 1. Choose one applicable EBP article (within 5 years; United States studies only) that supports your management plan. Summarize the article s findings, strengths, and weaknesses. Discuss the implications for practice. 2. Ask 2 critical thinking questions to engage the group and lead a discussion. 20 Brief overview of your clinical rotation and the role of your preceptor 5 Utilize PowerPoint to Enhance Learning 1. Slides are easy to read and support the main points of the talk 2. Uses slides as cues does not read from them 3. Slides include appropriate citations and reference slides are provided 10 Overall Presentation Style 1. Speaks clearly and at an understandable pace 2. Dresses appropriately and portrays confidence 3. Maintains professionalism at all times 4. Observes 20-minute time limit 10 Submitted Power Point slides to clinical instructor 24 hours in advance 5 Instructor: Total score: / 100 Appendix C: NPST/Typhon Data Quality Checklist 13

Directions: Review your NPST/Typhon entries and check off the elements that are current (or not) and correct items that are incorrect or incomplete. After all columns are checked yes submit your checklist via SafeAssign. It is highly recommended that you enter your data daily and check the quality of your data and scheduler weekly. After each clinical day you are expected to log encounter data directly into the Typhon/NPST site online. NOTE: You will have a maximum of 2 weeks following your clinical encounter to enter data for your case log and time log records. Any further delay and you risk losing your ability to post your past clinical hours. Elements of Data Entry Present? Yes No Patient care hours and shift time: [Location: My Time Logs] Shift time is accurate and complete Columns are entered correctly for each clinical day: [Location: My Time Logs] Patient Time (from case logs) Other columns (simulation, workshops, standardized patient, conferences) recorded accurately as appropriate Demographics and visit characteristics, social problems, coding: Review of case log totals should reveal complete demographics and visit characteristics with identified social problems CPT and ICD-10 codes are accurate and complete [Location: Case Log Totals (Graphical); Daily/Weekly Case List (Spreadsheet)] Scheduler calendar: [Location: My Schedule] Scheduler accurately reflects all scheduled clinical days 225 Clinical hours per semester: [Location: Clinical Hours Achieved by Course] Clinical hours reflect progressive accumulation to reach 225 hours by the end of the practicum course NUPR 541 ONLY: Total clinical hours for all 3 practica = 675 clock hours Comments: Student Signature and date: (written or electronic) Appendix D: Competency-Based Clinical Evaluation Form 14

This competency-based clinical evaluation form is designed to track your development as a nurse practitioner student throughout the program. Arrange a time to review the evaluation with your preceptor and together make a learning plan to address any particular competencies to work on in the future. In this way you can make the most of your clinical hours. A hard copy of the evaluation form must be submitted to your clinical instructor. Alternately, evaluations may be submitted via or fax or email to your clinical instructor. Two evaluations are required for each clinical placement: a mid-point evaluation and final clinical evaluation from each practicum site. Both are used to calculate the final course grade. The evaluation uses a 0-1-2 scale. A straight 2 indicates you are meeting all the basic expectations for a student at this level and equates to a score of 85%. An item scored as 1 is an area to improve, and a 3 indicates an area in which you are doing exceptionally well. How your evaluation will be scored a) Points for items 1-14 are summed, divided by the number of items scored, and multiplied by 0.6 for the mean score for Management of Patient Health/Illness. This domain is weighted somewhat more than the other domains to reflect its importance. b) Points for items 15-27 are summed, divided by the number of items scored, and multiplied by 0.4 for the mean score for all other domains. c) The mean scores for Management of Patient Health/Illness and all other domains are summed and the sum averaged with any other midterm or final scores for the Evaluation Score. The Assigned Percent Score for midterm or final evaluation is then determined according to the following scale: Evaluation Score Assigned Percent Score 1.00 1.09 65% 1.10 1.19 68% 1.20 1.36 72% 1.37 1.59 75% 1.60 1.76 78% 1.77 1.99 82% 2.00 2.16 85% 2.17 2.34 88% 2.35 2.49 92% 2.50 2.66 95% 2.67 2.84 98% 2.85 3.00 100% UIC CON NP STUDENT COMPETENCY CLINICAL EVALUATION FORM 15

Student: Date: Preceptor: Site: Please circle evaluation cycle: Hours Student Completed Thus Far: Mid-term Final This form is used by the clinical preceptor for feedback to the student and UIC faculty at midterm and the end of each practicum. Please fill it out considering the level of the student using the following key: 1 = below expectations for this level of student 2 = meets the basic expectations for this level of student 3 = exceeds expectations for this level of student NA/NO = not applicable/not observed Criteria for Evaluation Management of Patient Health/Illness Status 1.Obtains a comprehensive and/or problem focused health history 2. Performs a comprehensive and/or problem focused physical exam 3. Documents accurately a relevant health history and physical exam 4. Differentiates normal, variations of normal and abnormal findings 5. Synthesizes data from a variety of sources to make clinical decisions regarding appropriate management, consultation or referral 6. Prioritizes health problems including the need for emergent care 7. Provides anticipatory guidance and counseling for patients and families 8. Employs appropriate diagnostic, procedural and other interventions with attention to safety, cost, risk and benefit 9. Analyzes and interprets the history, physical findings, and diagnostic information to develop appropriate differential diagnoses 16

10. Prescribes appropriate pharmacologic and nonpharmacologic treatment modalities based on relevant individual client characteristics 11. Evaluates interventions and revises plan accordingly 12. Uses evidence-based references effectively and efficiently in the clinical setting 13. Presents patients to preceptor in thorough, concise, and organized manner 14. Completes patient encounter in a timely manner Nurse Practitioner-Patient Relationship 15. Demonstrates effective communication and therapeutic relationships with individuals, families, and caregivers 16. Demonstrates cultural awareness and sensitivity 17. Collects, maintains and documents health care information in a confidential and private manner following current rules and regulations Teaching-Coaching Function 18. Collaborates with the individual, family, and caregivers in the development of appropriate interventions 19. Adapts teaching-learning approaches based on the physiological and physiological changes, age, developmental stage, readiness to learn, health literacy and the resources Professional Role 20. Maintains professional standards, including but not limited to demeanor, language, appearance, timeliness, and behavior 21. Collaborates and consults with the preceptor and with other health care providers to optimize care and outcomes for the adult-gerontology population 22. Applies current, relevant evidence into planning patient care 23. Demonstrates interest and takes initiative in learning Managing and Negotiating Health Care Delivery Systems 24. Considers cost, safety, effectiveness and alternatives when 17

making health care decisions 25. Applies knowledge of regulatory processes and principles of payer systems when planning care Monitoring and Ensuring the Quality of Health Care Practice 26. Uses technology and quality improvement methods to enhance safety and monitor health outcomes Cultural and Spiritual Competence 27. Shows respect and incorporates individual, cultural, ethnic and spiritual needs of the patient and their families into the plan of care Strengths: Areas needing improvement: Additional comments: Student Signature: Date: *Preceptor signature: Date: *Preceptors are requested to send a completed evaluation to the student s clinical faculty contact as below via email (scanned) or fax (see next page, please): Chicago: Adult-Gero Acute Care Melissa Carlucci: mcarlu2@uic.edu Fax: 312-996-4979 Adult-Gero Primary Care Leah Burt: lcalli2@uic.edu Fax: 312-996-4979 18

Rockford: Rich McLaughlin rhamcmc@uic.edu Fax: 815-395-5816 Urbana: Patricia Reichard Reichard@uic.edu Fax: (217)-244-0430 Quad Cities: Alyssa Wislander awisla2@uic.edu Fax: (309)-757-9473 Peoria: Sue Copp scopp2@uic.edu Fax (309) 671-8436 19