HTML Preview Nurse Self Evaluation Sample page number 1.
January 2013 Virginia School Nurse Institute Partnership
(Name of School Division/District)
School Nurse (Registered Nurse) Self-Evaluation Form
Employee Name:
School Year:
Position:
School:
Rating Scale: E= Exemplary P= Proficient D=Developing U=Unacceptable
Standard 1: Assessment, Diagnosis, and Outcomes Identification
E
P
D
U
1. Collects and analyzes data to identify student health needs and nursing diagnoses
(for example; health forms, screening results, clinic visits) for the school population.
2. Maintains records and evaluates student health data guided by clinical judgment and
current research.
3. Collaborates with family, faculty, and health care providers as needed to validate
data.
4. Identifies culturally appropriate short-and long-term student health outcome goals to
address needs and documents outcomes as measurable goals.
5. Serves as case manager for students with acute or chronic health needs.
Professional evidence or example(s):
Standard 2: Planning
E
P
D
U
1. 1. Uses evidence-based information to develop student individualized health care plans
(IHP) to achieve expected outcomes to specific interventions.
2. 2. Collaborates with school staff to plan strategies to promote appropriate use of school
clinic.
3. Develops plans for emergency care.
4. Collaborates with school personnel in crisis/disaster planning.
5. Utilizes an efficient system of documenting care appropriately.
6. Develops plans for other school personnel to handle health situations when the
licensed professional nurse is not available.
Professional evidence or example(s):