Escolar Documentos
Profissional Documentos
Cultura Documentos
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
A-5-9
A-6
A-7
Year
20 15
Year
20
Year
20
Year
20
Year
20
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
3
3
2
3
3
Page 1
nd
Year
20 15
Competency
Number
A-8-2
B: Nursing Process
B-1
B-2-2
B-2-3
B-3
B-3-2
B-4
C-1 to
C-4
C-5-1
C-6-1
C-7-1
C-12
D-2
D-3
D-3-7
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)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
3
3
3
3
Rating
(1-5)
C: Safety
Year
20
2
2
2
2
2
Rating
(1-5)
2
2
2
2
Year
20 15
Competency
Number
D-4
D-5
D-7
D-8-1
D-8-2
W: Professionalism
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
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)
2
2
2
2
2
Rating
(1-5)
2
2
2
2
2
2
2
2
2
2
2
Rating
(1-5)
2
2
Year
20 15
Competency
Number
X-4
X-7-1
X-7-3
X-7-4
Year
20
Year
20
Year
20
Year
20
4
2
2
4
SELF-ASSESSMENT SUMMARY
Year
Competency
Number
A
20 15 _
20 15_
20 15 _
D
20 15
_
W
20 15 _
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
20
15
Competency
Number
A
20 16 _
B
20 16 _
D
20
16_
Rating
(1-5)
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 20 15
Learning Objectives
(What I am going to learn?)
Resources &
Strategies (What will I
do to meet objectives?)
Target
Date
(Realistic
time
frame for
Evalu
ation
(How will I know I
learned it?)
nursing process. If I
am able to prioritize
the task then I know
I Learned it.
Professional Activity
Summary of Learning
1
WHMIS course
December
2015
1
Human Blood borne
December pathogen exposure.
2015
1
Its you move.
December
2015
12
November
2015
Name:
CPR course
CLPNA Registration #:
Professional Activity
Summary of Learning
CLPNA Registration #: