University of Perpetual Help System-Las Pinas Campus

LAS PINAS CITY

COLLEGE OF NURSING

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST

Concept: Acute Biological Crisis

Area: EMERGENCY ROOM

Name: ________________________ Date: ________________

Year___ Section___ Group Number___ Rating: _______________

Direction: Put a check on the skills observed / performed, of not please include remarks on the space
provided.

Legend:

3- Is at a very satisfactory level. Has thorough knowledge and understanding of the said case/topic.
Could do and plan intervention on his/her own.

2- At satisfactory level. Has enough understanding to handle the case but needs Careful guidance.

1- Needs to be reevaluated. Competency is at an unsatisfactory level and needs to be reoriented on

the subject/case at hand.

A. ASSESSMENT 10% Wt 3 2 1 Score Remarks

1. Assess different manifestations that are related 2

to Acute Biological Crisis through the different
methods used in physical and appropriate data
gathering.
2. Performs physical examinations correctly and 2
with confidence.
 3. Identifies and differentiates between normal and 2
abnormal findings in Acute Biological Cases.
4. Determines the significance of laboratory and 2
diagnostic findings to the emergent problems
5. Picks out critical and essential data in nursing 2
history relevant to the current situations.
Subtotal 10

A. PLANNING 4% Wt 3 2 1 Score Remarks

1. Knowledge in setting goals and prioritization of 2

patients needs with Acute Biologic Crisis in the
emergency room.
2. Identify changes in patient’s needs and nursing 2
problems as they occur and make necessary
adjustments in nursing measures.
Subtotal 4

A. INTERVENTIONS 15% Wt 3 2 1 Score Remarks

1. Assess the capability needed by the client 1

for self-management in the emergency.
2. Ensures safety, comfort and privacy in 2
rendering care of patients with acute
biologic crisis.
3. Provides necessary curative measures. 1

4. Provides immediate 1
restorative/rehabilitative measures during
temporary stay in the ER.
5. Utilizes available physical and 1
professional resources.
6. Makes referrals to appropriate health 1
professionals, as needed.
7. Shows commitment to the welfare of the 1
client.
8. Implements the plan of care jointly with 1
the client.
9. Performs nursing procedures/activities: 1
9.1 with ease and confidence
9.2 correctly 1

9.3 systematically 1

9.4 practices bioethical principles in care 1

 9.5 provides after care 1

9.6 demonstrate situational flexibility and 1

adaptability
Subtotal 15

A. EVALUATION 4% Wt 3 2 1 Score Remarks

1. Evaluates plan of care of client using the 1

outcome criteria and performs appropriate
documentation and recording of changes in the
client’s evident status after the interventions.
2. Displays critical thinking in the analysis of the 1
current management being employed and
modifications that has to be done as needed.
3. Discusses with the appropriate health team results of 1
interventions.
4. Accepts suggestions, constructive criticisms and 1
employ appropriate modifications in the plan of
care.
Subtotal 4

Grand Total 100

________________________ _________________________

Student’s Signature Clinical Instructor’ Signature

University of Perpetual Help System-Las Pinas Campus

LAS PINAS CITY
 COLLEGE OF NURSING

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST

Area: OPERATING ROOM

Name: ____________________________ Date: _________________

Year___ Section___ Group Number___ Rating: _______________

Direction: Put a check on the skills observed / performed, of not please include remarks on the space
provided.

Legend:

3- Is at a very satisfactory level. Has thorough knowledge and understanding of the said case/topic.
Could do and plan intervention on his/her own.

2- At satisfactory level. Has enough understanding to handle the case but needs Careful guidance.

1- Needs to be reevaluated. Competency is at an unsatisfactory level and needs to be reoriented on

the subject/case at hand.

A. ASSESSMENT 10% Wt 3 2 1 Score Remarks

1. Obtains and analyzes pertinent data concerning 2

patient’s condition.
2. Determines and categorizes clinical assessment 2
of the patient.
3. Interprets prudently the physician’s order. 2

4. Checks and accomplishes pre-operative 2

checklist prior to surgical procedure.
 5. Assess patient’s physiological, psychological 2
and patient’s emotional status.
Subtotal 10

A. PLANNING 4% Wt 3 2 1 Score Remarks

1. Formulates appropriate nursing diagnosis based 1

from thorough patients assessment.
2. Rationalizes principles of aseptic technique. 1

3. Checks functionality of the operating room / 1

delivery room equipment such as suction
machine, cautery and OR lights.
4. Prepares and selects surgical supplies 1
concerning the patient’s surgical procedure.
Subtotal 4

A. INTERVENTION 15% Wt 3 2 1 Score Remarks

Pre – Operative Phase

1. Identifies patient and verifies procedure to 1
be done.
2. Secures consent. 1

3. Checks for clearances (cardio-pulmonary 1

clearance, pedia clearance), diagnostic
procedures.
Intra – Operative Phase

1. Explains proper position for induction of 2

anesthesia and operation to be performed.
2. Demonstrate proper aseptic/antiseptic 2
technique, sterile drapings and handling of
instruments.
3. Maintains sterility of the operating room and 2
sterile field.
Post – Operative Phase
 1. Monitors vital signs immediately after the 2
operation.
2. Evaluates patient’s recovery from anesthesia. 2

3. Discusses the emergency resuscitative 2

devices, equipment and emergency drugs in
the recovery room.
Subtotal 15

A. EVALUATION 4% Wt 3 2 1 Score Remarks

1. Evaluates plan care after applying 1

necessary nursing interventions.
2. Discusses appropriate health teaching 1
(sterile wound care)
3. Performs proper documentation and 1
other important details are needed.
4. Participates in activity during post- 1
conference.
Subtotal 4

Grand Total 100

________________________ _________________________

Student’s Signature Clinical Instructor’ Signature

University of Perpetual Help System-Las Pinas Campus

LAS PINAS CITY

COLLEGE OF NURSING

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST

Concert: Staff Nursing

Area: GENERAL WARD

Name: ____________________________ Date: _________________

Year___ Section___ Group Number___ Rating: _______________

Direction: Put a check on the skills observed / performed, of not please include remarks on the space
provided.

Legend:

3- Is at a very satisfactory level. Has thorough knowledge and understanding of the said case/topic.
Could do and plan intervention on his/her own.

2- At satisfactory level. Has enough understanding to handle the case but needs Careful guidance.

1- Needs to be reevaluated. Competency is at an unsatisfactory level and needs to be reoriented on

the subject/case at hand.

A. KNOWLEDGE 3 2 1 REMARKS

1. Knowledge in gathering data

2. Knowledge of the different methods used in

physical assessment.

3. Adequate knowledge regarding normal values and

other laboratory results.

4. Identifies nursing problems of patient and its

cause.

5. Explains scientific principles behind patient’s

condition and management.

6. Knowledge in setting goals and prioritization of

patient’s needs.

7. Knows intervention to be given and the rationale.

8. Knows the theories and rationale behind nursing
procedures being implemented.

9. Knows the principle of drug administration and its

action.

10. Knowledge on how to relate nursing

interventions to outcomes.

Subtotal:

B. SKILLS 3 2 1 Remarks

1. Checks, records and interprets accurately the

vital signs of assigned patients.

2. Ability to manipulate and care for the equipment.

3. Ability to collect specimens for the laboratory

examination.

4. Demonstrate skill in providing comprehensive

nursing care.

5. Performs nursing procedures with maximum

result with minimum time, effort and materials at
her/his level.

6. Implements nursing care according to priorities.

7. Provides health teaching for patient and his

family as manifested by good communication skill.

8. Coordinates with other members of the health

team with regards to patient’s condition.

9. Ability to transcribe doctor’s order.

10. Records accurately patient’s conditions and

nursing intervention.

Subtotal:

C. ATTITUDES AND VALUES 3 2 1 Remarks

 1. Punctuality and regular in attendance.

2. Professionalism in uniform.

3. Honesty and sincerity.

4. Resourcefulness and creativity.

5. Sense of responsibility.

6. Initiative, Diligence and Industry.

7. Tolerance and Patience.

8. Polite and Respectful to self and others.

9. Works harmoniously with others.

10. Aware and understands the needs and emotions

of others.

Subtotal:

_____________________ ________________________

Student’s Signature Clinical Instructor’ Signature

 University of Perpetual Help System-Las Pinas Campus
LAS PINAS CITY

College of Nursing

Name: ____________________________________Date:___________________

Yr/Sec: ______________Group:___________ rating: __________________

Area: ____________________Clinical Instructor: __________________________

P E R F O R M A N C E E V A L U A T I O N T O O L

(STUDENT HEAD NURSE TO STUDENT NURSE)

NUMERICAL
QUANTITATIVE DESCRIPTION
RATING

Outstanding Carries out expected tasks in a very consistent manner with

5
minimal guidance and supervision

Very Carries out expected tasks in a consistent manner with

4
Satisfactory minimal guidance and supervision

Satisfactory Carries out expected tasks in a moderately consistent

3
manner with frequent guidance and supervision

Needs Carries out expected tasks in a rarely consistent manner

2
Improvement with close guidance and supervision

Unsatisfactory Does not carry out expected tasks even with close guidance
1
and supervision

PERFORMANCE RATING

I. ASSESSMENT / PLANNING

1.1 Establishes rapport with subordinates

1.2 Able to involve patients in plan of care

1.3 Punctual and prompt in all activities

1.4 Able to maintain stability under pressure

1.5 Gathers data using interview, observation, records review and

reports

1.6 Formulates appropriate nursing care plan

1.7 Wears complete prescribed RLE uniform

II. IMPLEMENTATION

a. Carries out assigned tasks based on the criteria of distribution of

assignments

b. Follows principles of time management

c. Equipped with required paraphernalia for RLE

d. Observes proper channels of communication

e. Carries out plan of care, including:

A. Bedside Care

B. Administration of medications

C. Administration of treatments (nebulization, IVF)

f. Shows initiative in performing tasks

g. Accomplishes delegated tasks within prescribed time frame

h. Provides psychological and spiritual support to patients

i. Accepts supervision and criticisms

j. Conducts appropriate health teachings

III. EVALUATION

1. Notifies immediate superior about untoward situations or conditions

related to patient care in the area

2. Make revisions in the plan of care as necessary

3. Evaluates Nursing Care rendered

V. ETHICOLEGAL CONSIDERATIONS

1. Demonstrates honesty at all times

 2. Conducts self in a tactful manner

3. Keeps confidential patient information

4. Observes the PNA Code of Ethics

5. Guided by RA 9173

6. Observes the 11 Core Competency Guidelines

REMARKS :

ACTUAL SCORE x 100 EVALUATED BY :

STUDENT HEAD NURSE

TOTAL SCORE

CONFORME BY :

STUDENT STAFF NURSE

NOTED BY:

CLINICAL INSTRUCTOR

University of Perpetual Help System-Las Pinas Campus

LAS PINAS CITY
College of Nursing
 HEAD NURSE PERFORMANCE CHECKLIST

Name: ____________________________________Date:___________________

Yr/Sec: ______________Group:___________ rating: __________________

Area: ____________________ Clinical Instructor: __________________________

A. Knowledge 5 4 3 2 1

1. Applies as appropriate theory as a basis for decision

making in nursing practice.
2. Assesses staffs presenting symptoms to determine
a nursing diagnosis and plan of action based on a
medical expertise and knowledge.
3. Knowledge in communication, clarification and
interpretation of existing problems with staff and
nursing responsibilities.
4. Inform the staff of the likely causes of errors defects
and waste.
5. Suggest in which risk, errors, quality of problems
maybe reduce.
A. Attitude
1. Neat and well groomed. Adheres to dress code.
2. Punctual in reporting for duty
3. Complies with the code of ethics of the nursing
profession and upholds and implements school
rules.
4. Assist in training staff in particular by setting a good
example.
5. Promotion of professional responsibility,
accountability and behavior.
A. Skills
1. Provide leadership in the assessment, planning,
implementation, and evaluation of comprehensive
school health program.
2. Respond to the student/ staff medical emergencies.
3. Instruct subordinates in appropriate method and
procedure in providing care.
4. Initiate and facilitate any steps necessary to improve
methods, equipments, materials and condition in the
 work area for which they are responsible.

Equivalent: ______________ Rating: _______________

Point Grade Equivalent

scale

5 85 Excellent Carries out expected behavior in a very consistent and

independent manner with less supervision and guidance.

4 82-84 Very Carries out expected behavior in a consistent and

Satisfactory independent manner that requires minimal supervision and
guidance.

3 79-81 Satisfactory Carries out expected behavior in rarely independent manner

requiring more supervision and guidance.

2 75-78 Fair Carries out expected behavior in rarely independent manner

requiring close supervision and guidance.

1 74 and Needs Carries out expected behavior under close supervision and
below improvement guidance.
Name: _____________________ Area: ___________________________

Yr/sec./Group#:______________ Clinical Instructor: _________________

Scaling Interpretation

This evaluation is to determine and appraise the performance of the staff according to
their assign task. By writing the appropriate score in the proper column denoting the extent to
which the nurses performed these functions.

Criteria for Grading

15% Decorum Attendance-------------------------------------------

20% Requirements-----------------------------------------------------

25% Quiz-----------------------------------------------------------------

40% performance------------------------------------------------------

_____________

Total 100%

Prepared By:

ROMMEL JOHN A. ALAVAZO

BSNIV-(IV) Group 3A
 PERFORMANCE CHECKLIST

KNOWLEDGE 5 4 3 2 1

1. Gathers data appropriately and completely, then

validating it focusing function needing assistance
support
2. Analyze and interpret collected data

3. Knows the correct way of doing physical

assessment.
4. Gives attention and synthesize the significant
laboratory findings
5. Knowledge in identifying nursing problems and
categorizing it according to the patients need.
6. Knows the rationale behind every intervention
given for the care of the patient.
7. Have knowledge in giving proper instruction for
medicine
a. classification
b. nursing responsibility
c. drugs and solution
1. Explain or discuss the report clearly and able to
answer question correctly.
2. Knowledge in preparation of patient for any
diagnostic procedure
3. Knows how to formulate an accurate nursing care
plan for particular cases.

SKILLS 5 4 3 2 1

1. Ability to give and respond to the care needed by

the patient
2. Perform procedure properly such as doing
physical assessment, taking VS, and giving
medication as ordered.
3. Able to provide or assist patient in performance
of activities of daily living whenever needed.
4. Always guided in precautionary and preventive
measure in providing care to the patient.
5. Able to give health teachings clearly to the
patient.
6. Communicate effectively in identifying the needs
of the patient.
7. Properly handling an instance of emergency
situation.
8. Implement Nursing care plan appropriately

9. Reassesses patient to determine whether a

remodification of care plan is necessary.
10. Able to conduct discharged planning with the
patient, his family and significant others.

Legend:

5 – Outstanding (85)

4 – Very Satisfactory (83-84)

3 - Moderately satisfactory (81-82)

2 – Minimally satisfactory (75-80)

1 – Unsatisfactory (74 and below)