Name: _______________________________________ Hospital: ____________________

Clinical Instructor: _____________________________ Date: _______________________

Shift: _______________________

OPERATING ROOM REQUIREMENTS

RUBRICS FOR REQUIREMENTS

PACU

CRITERIA RATING
Observations contain best details, are well-selected and very substantial
Submitted ahead of/on schedule 91 - 100
Observation contain better details, are well-selected and substantial.
Submitted ahead of/on schedule 81 - 90
Observation contain acceptable details, some are well selected and substantial
Submitted ahead of/on schedule 71 - 80
Observation contain few and minimal substance
Submitted within 3-12 hours after the scheduled time 61 - 70
Some observations contain acceptable details, are limitedly selected with
minimal substance 50 - 60
Submitted within 12-24 hours after the scheduled time.
Observations contain few details, are not well-selected and have very minimal
substance <50
Submitted within 24-36 hours after the scheduled time
No entry, with fewer words or sentences
Submitted after 36 hours after the scheduled time 0

REQUIREMENTS RATING SUGGESTIONS FOR

IMPROVEMENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
AVERAGE

QUIZ
PERFORMANCE EVALUATION

1
Students Name: _________________________________ Date: ______________________
Clinical Instructor: ________________________________ Place:______________________

GENERAL AND SPECIFIC OBJECTIVE (GOSO)

GENERAL OBJECTIVE:

SPECIFIC OBJECTIVES: (KNOWLEDGE, SKILLS AND ATTITUDE)

PLAN OF ACTIVITIES: (DAILY)

TIME ACTIVITIES
st
1 DAY 2nd DAY

2
 DOCTORS ORDER

DIRECTIONS: Copy the Doctors Order on the chart and provide your rationale each order.

DATE/TIME DOCTORS ORDERS RATIONALE

3
 VITALS SIGNS MONITORING SHEET

DIRECTIONS: Summarize the vital signs and the intake and output monitoring sheet of your patients
on the tables below.

PATIENTS NAME:
DATE & TIME T HR/PR RR BP O Sat

INTAKE AND OUTPUT MONITORING SHEET

NAME OF
PATIENT:

DATE TIME INTAKE OUTPUT

IVF IVTT PO OTHERS TOTAL URINE STOOL OTHERS TOTAL

4
Medical Devices Used / Attached
Directions: Do a head to toe scanning of attached medical equipment/devices used by the client
preoperatively, intraoperatively and postoperatively. Draw and label the drawings and provide the
functions of each other.

5
PACU MONITORING SHEET
Fill-up and attach the PACU monitoring sheet in this page and discuss the result of the score.

6
POST OPERATIVE COMPLICATIONS NOTED:

Indicate if there are post-operative complications seen a few hours post-op and discuss why such
complication happen, state the different nursing and medical intervention to correct the problem.
(Example : HYPOTENTION, DESATURATION, HYPOTHERMIA )