Professional Documents
Culture Documents
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2nd Edition - Revised October 2008
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2nd Edition - Revised October 2008
TABLE OF CONTENTS
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2nd Edition - Revised October 2008
SELF-ASSESSMENT TOOL
The Self-Assessment Tool is used to assess your professional practice using the LPN Standards of
Practice and Competency Profile as a guide. Focus your assessment on your practice as a whole and
then those Specific Competencies which are directly related to your role and responsibilities.
RATING SCALE Use the following rating scale to complete your Self-Assessment.
1
Excellent
2
Competent
3
Requires
Improvement
4
Developmental
Demonstrates
excellence in the
expectations and /
or requirements of
the competency.
Meets the
expectations and /
or requirements of
the competency.
Has identified
weakness in
areas of
knowledge, skills,
attitudes, or
clinical judgment.
Requires
education and/or
orientation to
meet the
expectations and /
or requirements of
the competency.
5
Not Applicable
Not applicable to
current role and
responsibility.
A: Nursing Knowledge
Year
2014
Year
20__
Year
20__
Year
20__
Year
20__
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
A-1
A-2
A-3
A-4-4
A-5-9
A-6
A-7
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2nd Edition - Revised October 2008
Year
2014
Competency
Number
A-8-2
B: Nursing Process
Rating
(1-5)
B-2-2
B-2-3
B-3
B-3-2
B-4
Year
20__
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
C-1 to
C-4
C-5-1
C-6-1
C-7-1
C-12
2
Rating
(1-5)
D-1
D-2
D-3
D-3-7
Year
20__
Rating
(1-5)
Year
20__
B-1
C: Safety
Year
20__
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Year
2014
Competency
Number
D-4
D-5
D-7
D-8-1
D-8-2
W: Professionalism
Rating
(1-5)
W-1-3
W-2-3
W-3
W-4
W-4-5
W-5-1
W-6
W-7
W-9
W-9-4
W-11
Rating
(1-5)
X-1-5
X-3-5
Year
20__
Year
20__
Year
20__
Year
20__
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
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Year
2014
Competency
Number
X-4
X-7-1
X-7-3
X-7-4
Year
20__
Year
20__
Year
20__
Year
20__
SELF-ASSESSMENT SUMMARY
Year
2014
2014
Competency
Number
A-3
A-5-9
A-6
A-7
A-8-2
B-1
B-2-2
C-6-1
C-12
2014
2014
2014
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
D-4
D-7
D-8-1
W-1-3
W-9
X-1-5
X-4
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Competency
Number
2014
D-4-6
2014
G-5-4
Rating
(1-5)
2014
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2nd Edition - Revised October 2008
2014
2014
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2nd Edition - Revised October 2008
Your Learning Plan must consist of at least TWO objectives for each year. You are required to fill out
all FOUR columns for each objective. Transfer your Learning Plan onto your Annual CLPNA
Registration Renewal Form. Please refer to the Guidelines at www.clpna.com for more information.
YEAR 2013
Learning Objectives
Target Date
Evaluation
(Realistic time
frame for
achievement)
March 2, 2015
(This is the start
of the next
clinical
placement)
____________
_
_____________________
1) A-3-4
I will increase my
knowledge of the
pathophysiology related
to diabetes, more
specifically, the
complications related to
diabetes
____________________
2) U-7-3
I will improve my
efficiency in hanging IV
medications and using
the smart pump.
Reviewing the
pathophysiology textbook
in regards to diabetes.
Researching medical
journals on library
database that relates the
complications that
diabetes presents in
patients
_____________________
Practicing how to use
pumps in open labs at the
college
Reviewing videos
provided from labs/ lab
manual on how to hang
IV medication
March 2, 2015
(By Next
clinical start
date)
I will be able to
efficiently, in under 10
minutes, hang IV
medication and set up the
IV smart pump
I will have decreased
questions for my buddy
nurse about the pump
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Professional Activity
(include course,
seminar, research,
hours, details)
1 Hour
G-5-1
Attended a buddy shift
at the U of A orthopedic
surgery unit, observed
and assisted buddy
nurse in dressing change
on post-operative
patients
Summary of Learning
6 Hours
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