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MLT 226: Practicum I Evaluation

Clinical Information
Student's Name:
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Date of Rotation:
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Clinical Evaluator:
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Supervisor Email:
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Date of Evaluation:
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Affective Domain Grading Scale
E=Excellent 96%
S=Satisfactory 87%
I=Improvement Needed 70%
U=Unsatisfactory 0%
Time Management
The Student:
E = Demonstrates time management skills that exceed the expected level (comes early, demonstrates initiative and efficiency in performing laboratory testing).
S = Is punctual; begins work in a timely manner; completes assignments within assigned time frame.
I = Is occasionally late; occasionally has problems beginning work in a timely manner; some assignments not completed within assigned time frames.
U = Is often late; has difficulty "getting started" on work; consistently fails to meet assignment deadlines.
Workload Management
The Student:
E = Show more organizational skills than most entry-level bench technicians.
S = Can organize work and produce required quantity of work with accuracy within the allotted time frame.
I = Occasionally has trouble organizing work; usually produces required quantity of work with accuracy within the allotted time.
U = Consistently requires help with organization; cannot complete required quantity of work with accuracy within allotted time; must always ask questions in order to complete the task.
Facilities Management
The Student:
E = Demonstrates initiative by cleaning, restocking, and adhering to regulation without directive to do so at all times.
S = Leaves work area clean and restocked; properly uses and maintains equipment; adheres to all published safety regulations in the laboratory.
I = Often leaves the work area dirty and unstocked; usually properly uses and maintains equipment and is not willfully negligent; occasionally violates published safety guidelines.
U = Does not leave work area clean and restocked even with reminding; willfully damages equipment; willfully violates published laboratory safety regulations.
Professionalism
The Student:
E = Is an exemplary professional at all times, in all circumstances.
S = Willingly follows instructions and accepts professional constructive criticism regarding work; interacts with faculty and students in a professional manner, e.g., is polite, considerate, pleasant, unhurried.
I = Occasionally fails to follow instructions and/or accept professional constructive criticism with little resistance; occasionally interacts with faculty and other students in an unprofessional manner.
U = Is willfully disobedient and insubordinate; acts unprofessionally, e.g., is abusive toward faculty members or other students.
Professionalism Part 2
The Student:
E = Handles work in logical sequence; is fully aware of own limitations; seeks help when needed.
S = Generally handles work in a logical sequence; is aware of own limitations; seeks help when needed.
I = Occasionally handles work in illogical sequence; is somewhat aware of own limitations; often seeks help before thinking the situation through. Asks many questions as a result of insecurity.
U = Has difficulty handling work in logical sequence, even after direction; does not recognize limitations even after limitations are pointed out; refuses to seek help or requires constant supervision/help.
Please comment on any I or U responses for the Affective Section: (600 Letters Max)
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Technical Objective Grading Scale
E=Excellent 96% Student is capable of performing tests without supervision after adequate training in the procedure.
S=Satisfactory 87% Student is capable of performing tests with minimal supervision after adequate training in the procedure.
I=Improvement Needed 70% Student is capable of performing tests with moderate supervision after adequate training in the procedure.
U=Unsatisfactory 0% Student is incapable of performing tests with direct supervision after adequate training in the procedure.
NP=Demonstrated but Not
Performed		 Procedure demonstrated and student understands the principle and purpose of the test.
NA=Not Applicable Procedure not available (not demonstrated or performed).

General Laboratory Practice E S I U NP NA
1. Follows test procedures-does not take short-cuts.
2. Well organized work area-keeps area neat and clean.
3. Demonstrates proper use and care of laboratory glassware, supplies, and instruments.
4. Pipets accurately.
5. Demonstrates safety within the laboratory.
6. Interprets test results correctly.
7. Recognizes normal and abnormal results.
8. Recognizes "alert" or "critical" values and demonstrates an understanding of importance of such values.
9. Notifies technologist/supervisor when abnormal and "critical" values are obtained on patient specimens.
10. Demonstrates ability to use computer for calculations and data entry.
11. Performs appropriate Quality Control for test procedures
12. Records Quality Control results correctly.
13. Notifies supervisor when Quality Control results indicate a need for corrective action.
14. Perform laboratory calculations (such as dilutions, solution, manual procedure calculations, etc.) correctly.
15. Demonstrates an understanding of the principles of each of the test methods performed during rotation.
16. Performs specimen evaluation and accessioning.
17. Provides notification and clarification on problem specimens.
18. Processes send out on specimens.
19. Initiates timely response to STAT requests.
20. Complies with federal laws, regulations, and guidelines.
21. Resolves/refers operational problems.
22. Correctly prepare and label reagents.
23. Monitors reagent stability/sterility and expiration.
24. Demonstrates proper use and care of the microscope.
24a. Please comment on any I or U responses for the General Lab Section: (600 Letters Max)
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Chemistry E S I U NP NA
25. Operates (including calibration, monitoring, and preventive maintenance) various chemistry instrumentation properly.
25a. Instruments the student can operate: (200 Letters Max)
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26. Performs chemical laboratory procedures utilizing manual and/or automated techniques and obtains results within acceptable limits of accuracy for each analyte (electrolytes; carbohydrates; lipids; non-protein nitrogenous substances like BUN, creatinine, uric acid; enzymes; hormones; drugs; proteins)
26a. Please indicate any of the above tests NOT performed by the student: (100 Letters Max)
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26b. Please comment on any I or U responses for the Chemistry Section: (600 Letters Max)
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Hematology E S I U NP NA
27. Operates (including calibration, monitoring, and preventive maintenance) various hematology instrumentation properly.
27a. Hematology instruments the student can operate: (200 Letters Max)
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28. Prepares, labels, and stains acceptable peripheral blood smears.
29. Examines peripheral blood smears, performing platelet & WBC estimates recognizing normal and abnormal RBC, WBC, and platelet morphology and maturation stages.
30. Performs hematology laboratory procedures utilizing manual and/or automated techniques and obtains results within acceptable limits of accuracy for each analyte (hemoglobin, hematocrit, Erythrocyte Sedimentation Rate, WBC counts, RBC counts, platelet counts, Red Blood Cell Indices, retic counts).
30a. List any of the tests in #33 not performed by the student: (200 Letters Max)
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31. Correctly performs cell counts on other body fluids.
32. Demonstrates principles and techniques of a variety of different coagulation procedures utilizing manual and/or automated techniques (bleeding times or PFA, prothrombin time/ INR, partial thromboplastin time, fibrinogen, fibrin degradation products (fibrin split products) or D-dimer).
32a. List any of the tests in #35 not performed by the student: (400 Letters Max)
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32b. Please comment on any I or U responses for the Hematology Section: (600 Letters Max)
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Urinalysis E S I U NP NA
33. Operates (including calibration, monitoring, and preventive maintenance) various urinalysis instrumentation properly.
33a. Urinalysis instruments the student can operate: (200 Letters Max)
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34. Performs correct macroscopic examination of urine.
35. Performs correct biochemical evaluation of urine.
36. Performs correct microscopic examination of urine.
37. Completes routine urinalysis in a timely fashion and reports patient values according to lab protocol.
38. Performs QC for biochemical and/or microscopic exam of urine.
39. Performs confirmatory tests as required per lab protocol.
39a. List confirmatory tests performed: (100 Letters Max)
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40. Performs and interprets occult blood testing of feces
41. Performs and calculates creatinine clearance.
42. Processes and handles all body fluids correctly.
43. Performs body fluid analysis.
43a. List the type of body fluid analysis performed: (200 Letters Max)
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43b. Please comment on any I or U responses for the Urinalysis Section: (600 Letters Max)
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Phlebotomy E S I U NP NA
44. Properly identifies patient prior to phlebotomy procedure.
45. Recognizes and utilizes only acceptable venipuncture sites.
46. Properly selects the correct collection tubes for various tests.
47. Initials, records collection times, notes any IV's being given.
48. Perform specimen collection procedures (venous, capillary, cultures, newborns) properly.
49. Handles isolation specimens properly.
50. Transports and processes specimens properly.
50a. Please comment on any I or U responses for the Phlebotomy Section: (600 Letters Max)
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Practicum I Comments
1. Are there any tests or procedures that the student should perform or repeat prior to graduation? (400 Letters Max)
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2. Did the student accomplish the learning experience YOU feel he/she should have accomplished during this clinical experience? (600 Letters Max)
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3. Is there anything you would like to compliment the student on? (600 Letters Max)
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4. Do you have other comments or suggestions? (400 Letters Max)
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A copy of this evaluation will be forwarded to the student


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