Clinical Skills Assessment Report (CI Form)
Skill/Performance / U / S / O / CommentsSAFETY
- Establishes/maintains safe working environment
- Recognizes and responds to physiological and psychological changes in the patient
- Demonstrates awareness of contraindications and precautions of the selected treatment
- Requests assistance when necessary
- Uses accepted techniques for patient handling
/
/
Foundational Knowledge
- Application of anatomy, biomechanics, pathology, physiology
Vital Signs(** Must be performed during affiliation)
- Measures: pulse rate, BP, RR
- Correctly interprets findings
/
/
Examination
- Screening
- Tests and Measurements (cognition, MMT, goniometry, reflex, sensation, balance, posture)
/
/
Intervention
- Therapeutic technology (US, ES, modalities)
- Gait training
- Therapeutic exercise
- Cardiopulmonary training
- Transfers/Bed mobility
- Positioning/draping
/
/
Documentation
- Selects relevant information
- Documents information correctly (spelling, medical terminology, organized, legible)
/
/
Communication
- Professional (verbal, non-verbal)
- Active listener
- Appropriate for recipient (terminology used, culturally and linguistically . . .)
/
/
Professionalism
- Appropriate attire
- Demonstrate initiative
- Accepts and responds to feedback appropriately
- Practices ethically (Code of Ethics) and legally
- Uses time effectively
/
/
Clinical Site: ______
Student’s Signature: ______Date: ______
Student: ______(please print)
Instructor’s Signature:______Date: ______
Clinical Instructor: ______(please print)
Dates of Attendance: ____/______/______/______/______/____
Clinical Skills Assessment Report (Student Form)
Skill/Performance / U / S / O / CommentsSAFETY
- Establishes/maintains safe working environment
- Recognizes and responds to physiological and psychological changes in the patient
- Demonstrates awareness of contraindications and precautions of the selected treatment
- Requests assistance when necessary
- Uses accepted techniques for patient handling
/
/
Foundational Knowledge
- Application of anatomy, biomechanics, pathology, physiology
Vital Signs(** Must be performed during affiliation)
- Measures: pulse rate, BP, RR
- Correctly interprets findings
/
/
Examination
- Screening
- Tests and Measurements (cognition, MMT, goniometry, reflex, sensation, balance, posture)
/
/
Intervention
- Therapeutic technology (US, ES, modalities)
- Gait training
- Therapeutic exercise
- Cardiopulmonary training
- Transfers/Bed mobility
- Positioning/draping
/
/
Documentation
- Selects relevant information
- Documents information correctly (spelling, medical terminology, organized, legible)
/
/
Communication
- Professional (verbal, non-verbal)
- Active listener
- Appropriate for recipient (terminology used, culturally and linguistically . . .)
/
/
Professionalism
- Appropriate attire
- Demonstrate initiative
- Accepts and responds to feedback appropriately
- Practices ethically (Code of Ethics) and legally
- Uses time effectively
/
/
Clinical Site: ______
Student’s Signature: ______Date: ______
Student: ______(please print)
Instructor’s Signature:______Date: ______
Clinical Instructor: ______(please print)
Dates of Attendance: ____/______/______/______/______/____
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