PERFORMANCE
APPRAISAL
REGISTERED
NURSE
Employee
Name:
Date:
Evaluator's
Name :
Title:
For
each area of performance evaluate the level of achievement demonstrated during
the past year.
AREAS OF PERFORMANCE
Autonomy
and Accountability
Patient
Care Management
Professionalism
LEVEL OF ACHIEVEMENT
5 - Outstanding
4 - Highly Effective
3 - Effective
2 - Improvement Needed
1 - Unacceptable
NA- Not Applicable
Areas of Performance Level
of Achievement
A. Autonomy
and Accountability
1.
Functions within legal framework of the
Nurse Practice Act of the state
currently
employed.
2.
Performs work assignment with
minimum
need for supervision and
guidance.
3.
Demonstrates reliability in meeting
deadlines
and completing
responsibilities.
4.
Possesses skills and technical
competence
to execute work
responsibilities.
5.
Demonstrates responsibility and
reliability
in meeting scheduled
Areas of Performance Level
of Achievement
6.
Operates within the established
company
guidelines ______
7. Complies with hospital policies
and procedures.
8. Assists with training/education of
staff,
contributes to an open learning
environment.
9. Displays ability to utilize appropriate
channel(s) for
communication and/or
problem solving.
10. Adheres to Hospital and Company
health and safety
standards.
B. Patient Care Management
1. Utilizes established Nursing
Department Standards in the
delivery of
patient care.
2. Utilizes clinical knowledge and skills
to assess the
needs of assigned
patients.
3. Completes and documents initial and
ongoing
assessments as per policy.
Written communication is clear, legible
and objective.
4. Prioritizes care based on medical and
nursing
diagnosis, nursing history, DRG
and expected
patient outcomes.
5. Demonstrates ability to set goals, assign
priorities,
anticipate problems, establish
limits and
achieve quality results.
6. Completes tasks with timeliness,
schedules and
uses time efficiently.
7. Develops comprehensive plan of care
from admission
to discharge for
assigned
patients based on patient
needs, standards
of care, DRG and
expected patient
outcomes.
Areas of Performance Level
of Achievement
8. Functions as a patient advocate
assuring patient's right to information,
providing
patient safety at all times, and
maintaining
confidentiality.
C. Professionalism
1. Promotes good public relations for
CCMS and Hospital.
2. Communicates accurately/appropriately
with patients,
family and other personnel.
Establishes and maintains therapeutic
and supportive
relationship.
3. Adheres to Company/Hospital dress
code policy.
4. Reports to work in a timely manner.
5. Effectively expresses self. Listens
attentively and
creates a climate of open
communication.
Respects confidentiality
and privacy.
6. Accepts constructive comments from
hospital/contracting
company as a
mechanism for
improvement.
7.
Maintains credentials and education
files as per JCAHO
standards and
Department of Health
Regulations.
8.
Functions as an integral part of the
health care
delivery team and participates
in the maintenance
of a cohesive work
environment.
Signature
of Clinical Nurse Date
__________
Signature of Branch/ Nurse
Manager
Date
Signature
of Division
Officer/Designee
Date
COMMENTS: Areas of performance
marked Level 1 or Level 2 must be accompanied by comments.
GOALS: