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Sample Form

Registered Nurse Performance Review Appraisal Score Overall Score:


Role Model = 3, Key Contributor = 2, Below Standard = 1 If the Overall Rating for the Value-added Results or Core Value Behaviors section is rated Below Standard and the other section is rated Role Model, change the Overall Rating for the performance review to 1.

/3

Performance Review
Review Date: Overall Rating for Value-Added Results Overall Rating for Core Vale Behaviors Role Model = 3, Key Contributor = 2, Below Standard = 1 Score: Score: /3 /3

Employee Identification
Name: Cost Center: Department: Badge ID: Job Title: Grade: Job Code: Division:

Part I Instructions:
Please indicate the appropriate rating code by clicking on the corresponding button and add comments at the end to individualize the document. Comments must be added for all items rated below standards or role model to specifically explain the rating. Rating Code: R=Role Model: Consistently produce results that exceed performance expectations. Others describe as a leader and team player. All not shared items rated Role Model. K= Key Contributor: Consistently produces results that meet or occasionally exceed performance expectations. For new employees performance reflects growth or progress in meeting expectations. All not shared items rated Key Contributor or Role Model. B= Below Standards: Results produced are below the performance expectations. Any not shared item rated Below Standards.

Part I Competency Review: Value-Added Result #1


Each patients individual care needs are identified and care is planned to achieve best clinical results. Patient assessment and care planning is evidence based and carried out according to standards of professional nursing practice. Continuous improvement of nursing practice. Measures: Chart review (N = 5 - 10) for documentation of assessment and care planning as defined below. (If documentation meets standards in 5 charts additional charts are not required.) Observation Comments:
Role Model Key Contributor Below Standards

Value-Added Result #2
Patients receive safe and effective nursing care. Patients receive age appropriate care. Patients' needs and response to care are evaluated and care is altered as necessary. Reduction in staff injury/ increased awareness of risk. Measures: Chart review (N = 5 - 10) for documentation of appropriate intervention and evaluation of care as defined below. (If documentation meets standards in 5 charts additional charts are not required.) Critical skills checklist System reports including patient falls, lost time injuries, event reports. Observation Comments:
Role Model Key Contributor Below Standards

Value-Added Result #3
Patient/family understand discharge plan. Patient/family understands care following discharge. Patient/family are satisfied with information and education received.
Role Model Key Contributor Below Standards

Measures: Chart review (N= 5 - 10) for evidence of documentation of patient and family teaching as defined below. (If documentation meets standards in 5 charts additional charts are not required.) Nurse Manager audits/rounds. Comments:

Value-Added Result #4
Patient/family are satisfied with nursing care received. Patient/family perceive the nursing staff as being responsive, caring and courteous Patient/family feel that they are included in decisions regarding their care. Patient satisfaction scores reflect that the patient/family believe the health care team is working together for them. Measures: Chart review (N= 5 - 10) for evidence of pain management. (If documentation meets standards in 5 charts additional charts are not required.) Nurse Manager interactions with patient/family. Nurse Manager observation Patient comments Comments:

Role Model Key Contributor Below Standards

Value-Added Result #5
Nursing practices and standards of care are evidence based and consistent with current national standards Patients receive high quality, cost effective care.
Role Model Key Contributor Below Standards

Measures: Practice changes Documentation of achievements Review of accomplishments Nurse Manager direct and indirect observation Comments:

Value-Added Result #6
Enhanced quality of patient care through a holistic approach. Teamwork Efficiency in administration of care and treatments. Improved patient satisfaction. Measures: Chart review (N=5-10) for documentation of appropriate intervention and evaluation of care as defined below. (If documentation meets standards in 5 charts, additional charts are not required.) Observation/feedback Comments:
Role Model Key Contributor Below Standards

Overall Rating for Value-Added Results Role Model = 3, Key Contributor = 2, Below Standard = 1

Score:

/3

Part II - Instructions:
Please indicate the appropriate rating code by clicking on the corresponding button and add comments at the end to individualize the document. Comments must be added for all reviews of below standards or role model to specifically explain the rating. Rating Code: R=Role Model: Consistently demonstrates Role Model level behaviors in addition to all Key Contributor level behaviors. Four out of six Core Values rated Role Model including Caring and Teamwork, remaining must be at least Key Contributor. K= Key Contributor: Consistently demonstrates defined Key Contributor level Core Value Behaviors. For new employees performance reflects growth or progress in meeting expectations. All Core Values at least Key Contributor. B= Below Standards: Does not consistently demonstrate Key Contributor Behaviors. Any Core Value rated below standards.

Part II. Core Value Behaviors I. Caring


Creates positive relationships with those served by putting them first in all interactions. Effectively meets the needs of those served in a compassionate, responsive and courteous manner. Comments:
Role Model Key Contributor Below Standards

II. Teamwork
Actively participates as a member of a team or department to get the work completed. Demonstrates flexibility and cooperation. Helps to remove obstacles for the team to reach goals. Comments:
Role Model Key Contributor Below Standards

III. Excellence
Strives for the highest quality in all aspects of work performance. Learns and uses new information, skills and knowledge. Assumes responsibility for improving care/services. Comments:
Role Model Key Contributor Below Standards

IV. Integrity
Role Model

Consistently demonstrates actions which are professional & responsible, portraying trustworthiness and dependability.

Key Contributor Below Standards

Comments:

V. Leadership
Role Model

Assumes responsibility for quality care and services and in all situations. Adapts positively to change.

Key Contributor Below Standards

Comments:

VI. Service
Take action to meet or exceed the expectations of those we serve. Those we serve include coworkers, physicians, patients, clients, residents, families, and visitors. It is our privilege to serve the community and we should treat this role as an honor. Be an ambassador for our health system in and outside of the workplace.
Role Model Key Contributor Below Standards

Comments:

Overall Rating for Core Value Behaviors Role Model = 3, Key Contributor = 2, Below Standard = 1

Score:

/3

Part III Other Performance Standards


Competency Critical skills are current. Attendance is within standard. Mandatory education is complete. Rating Comments:

Comments
Employee

Manager

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