Académique Documents
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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
20 16
4
4
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)
4
4
4
4
4
3
4
4
4
Year
20
C: Safety
C-1 to
C-4
Year
20
B: Nursing Process
B-1
Year
20 16
4
4
4
4
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
3
4
3
2
2
2
3
X-3-5
Year
20
W-4
X-1-5
Year
20
W: Professionalism
W-1-3
Year
20 16
Year
20 16
Competency
Number
X-4
X-7-1
Year
20
Year
20
Year
20
Year
20
2
3
X-7-3
X-7-4
SELF-ASSESSMENT SUMMARY
Competency
Number
Year
All
20 16 _ specific
A-2
B-4
D -7
20
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
As a student all the areas are in this range, as I still have very limited nursing experience My knowledge is
from books, and my placements, with very limited hands on experience. Even though I did learn a lot, I have
so much more to learn to be a great nurse. Two main areas where I want to work on are
Applies knowledge of microbiology throughout care, disease prevention, and health promotion
Evaluates the clients response to care and treatment.
Applies clinical judgment in identifying problems and resolving issues in client care.
.
20
20
20
20
20
20
20
20
Competency
Number
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 16
Learning Objectives
Target Date
(Realistic time
frame for
achievement)
Evaluation
(How will I know I learned it?)
Applies knowledge of
microbiology throughout
care, disease prevention,
and health promotion
CLPNA Registration #:
Professional Activity
Summary of Learning
Name:
CLPNA Registration #:
Professional Activity
Summary of Learning
Name:
CLPNA Registration #: