Kingdom of Saudi Arabia
Jazan University
Ministry of Higher Education
College of Pharmacy
Department of Clinical Pharmacy
Clinical Training Unit
Internship Evaluation Form
Total Parenteral Nutrition (TPN)
Student name:…………………………………………………………………………………
Student ID:…………………………………………………………………………………
Rotation name:………………………………………………………………………………..
Rotation code:………………………………………………………………………………….
Location:……………………………………………………………………………………….
Training period:
From
/
/ 20
to
/
/20
Kingdom of Saudi Arabia
Jazan University
Ministry of Higher Education
College of Pharmacy
Department of Clinical Pharmacy
Clinical Training Unit
Internship Evaluation Form
Total Parenteral Nutrition (TPN)
General Guidelines for Preceptor
Kindly please read the following instructions:
1. The evaluation form is a confidential document; accordingly, the contents should
not be shared with anyone including the intern.
2. Continuous feedback to the intern is recommended in order to fill the gaps and
to strengthen the weak points that are observed during the training period.
3. Please make sure that the attendance form is signed by both preceptor and
intern.
4. If the intern is fails in the personal and ethical evaluation part, this will be
considered as an overall failure irrespective of the degree that has been awarded
in the other skills; consequently, the intern shall repeat the concerned rotation
for full duration.
5. Please make sure that the evaluation form together with the attendance form is
enclosed in a properly sealed and stamped envelope after evaluation.
6. The intern is fully responsible for submitting the sealed envelope enclosing
his/her evaluation form to the authorized person in the College of Pharmacy.
Your participation and great efforts are highly valued and appreciated by the College of
Pharmacy-Jazan University.
Kingdom of Saudi Arabia
Jazan University
Ministry of Higher Education
College of Pharmacy
Department of Clinical Pharmacy
Clinical Training Unit
Internship Evaluation Form
Total Parenteral nutrition (TPN)
A. Personal and ethical evaluation:
Total mark is 40
Parameter
Marks
Comments
Attendance
(out of 10)
Punctuality
(out of 10)
Professionalism
(out of 10)
With
healthcare
Attitude professionals
(out of 5)
With
patients
(out of 5)
Final mark for the personal and ethical evaluation:
/40
B. Pharmaceutical and communication skills evaluation: (Total marks is 60 divided as
the following):
i. Pharmaceutical Skills (Total mark is 50 divided as follow):
Activity
Score
1- Understanding the basic concepts of TPN calculations, preparation,
and storage.
……./5
2- Receiving orders and calculation of nutrient concentration
- Able to understand the TPN orders and calculate the nutrient
concentrations
……./10
3- Applying the IV/TPN room regulations:
- Able to understand the sterile policy and procedure of IV/TPN
room
- Able to apply the sterile procedures correctly
……./5
4- Understand the operation and function of equipment in the IV/TPN
room
- Understand the concept of airflow and filter systems used in
IV/TPN room
- Applying Laminar Flow Hood regulations
……./5
5- Preparing TPN preparations solutions (manually or with automated
systems)
……./15
6- Labeling preparations appropriately
……./5
7- Sending orders to floor, nurse stations, or patient room
……./5
8-
Prepare one of the following:
An article for the pharmacy newsletter if available.
An assignment related to IV/TPN preparations
Deliver a presentation related to TPN preparation
Optional
comments
ii: Communication skills (Total mark is 10 divided as follow):
Skill
With the healthcare
professional
(Out of 5)
With the patients
(Out of 5)
Mark
Final mark for pharmaceutical skills and communication skills :
Total mark:
Comments
/60
/100
Any additional comments:
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
Preceptor name:…………………………………………………………………………..
Specialty:………………………………………………………………………………….
Signature:…………………………………………………………………………………..
Stamp:………………………………………………………………………………………
Date:………………………………………………………………………………………..
Kingdom of Saudi Arabia
Jazan University
Ministry of Higher Education
College of Pharmacy
Department of Clinical Pharmacy
Internship Evaluation Form
Total Parenteral Nutrition (TPN)
ATTENDANCE FORM
Student name:
Rotation name and code:
Day
ID number:
Location:
Date
Student's signature
Preceptor signature