Professional Documents
Culture Documents
TABLE OF CONTENTS
nd
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
Assessment.
1
Excellent
2
Competent
3
Requires
Improvement
4
Developmental
5
Not Applicable
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.
Not applicable to
current role and
responsibility.
A: Nursing Knowledge
A-1
A-2
A-3
A-4-4
Year
20
Year
20
Year
20
Year
20
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
A-5-9
A-6
A-7
Year
2016
2
2
Page 1
nd
Competency
Number
A-8-2
B-2-2
B-2-3
B-3
B-3-2
B-4
C-5-1
C-6-1
C-7-1
C-12
D-2
D-3
D-3-7
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)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
2
2
2
2
2
2
2
2
2
Year
20
C: Safety
C-1 to
C-4
Year
20
B: Nursing Process
B-1
Year
20
2
2
2
2
Competency
Number
D-4
D-5
D-7
D-8-1
D-8-2
W-2-3
W-3
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)
Rating
(1-5)
Rating
(1-5)
W-4-5
W-5-1
W-6
W-7
W-9
W-9-4
W-11
2
2
1
1
1
2
2
X-3-5
Year
20
W-4
X-1-5
Year
20
W: Professionalism
W-1-3
Year
2016
Year
2016
Competency
Number
X-4
X-7-1
X-7-3
X-7-4
Year
20
Year
20
Year
20
Year
20
2
2
SELF-ASSESSMENT SUMMARY
Competency
Number
Year
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
W-11
X-7-3
X-7-4
Participates in committees, task forces and professional activities to offer the LPN
perspective.
2016
2016
2016
20
20
Competency
Number
Rating
(1-5)
W-11
X-7-3
2016
2016
20
20
20
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 2016
Learning Objectives
Target Date
(Realistic time
frame for
achievement)
Evaluation
(How will I know I learned it?)
1) I will keep
1) Attend a workshop on 1) September 1) I will be able to
informed of
a focused on a current 2017
present the information I
current research health issue in the
learned from the
2)
January
2020
in the medical
Edmonton area that is
workshop to my
field by attending presented by
colleauges.
a workshop to
nursinglinks.ca.
2) I will be given
assist me in
2) Complete Leadership
permission to preceptor
providing
a student at my place of
exceptional care for Licensed Practical
Nurses
course
through
employment.
to patients.
Bow Valley College.
2) I would like to
preceptor a
student during
my career after I
have gained
knowledge and
experience in the
field.
Name:
CLPNA Registration #:
Professional Activity
Summary of Learning
Name:
CLPNA Registration #:
Professional Activity
Summary of Learning
Name:
CLPNA Registration #: