Escolar Documentos
Profissional Documentos
Cultura Documentos
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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
2015
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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Year
2015
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
2015
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
2015
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
2015
Competency
Number
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
C1C4
W-45
X-3-5
X-4
20___
20___
20___
20___
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Rating
(1-5)
X-3-5
X-4
Competency
Number
2015
20___
20___
20___
20___
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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 2015
Learning Objectives
Target Date
Evaluation
(Realistic time
frame for
achievement)
Critical thinking in
nursing: A cognitive skills
workbook
By the end of
May 2015
Nursing leadership,
management, and
professional practice for
the LPN/LVN
Nursing leadership,
management, and
professional practice for
the LPN/LVN
Be able to prioritize
interventions during an
emergency situation
By the end of
May 2015
Be able to effectively
communicate with the
healthcare team during
my Preceptorship.
Reflection
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2nd Edition - Revised October 2008
October 9,
2014
Professional Activity
(include course,
seminar, research,
hours, details)
BLS FOR HCP (C)
4hours
Summary of Learning
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2nd Edition - Revised October 2008