ARELLANO UNIVERSITY

College of Nursing

RLE - CLINICAL PERFORMANCE CHECKLIST IN STAFF NURSING

Staff Nurse Name:

SKILLS (70%)
A. Utilization of nursing process
1. Utilizes the nursing process in the care of patients
1.1 Assesses needs of patient
1.2 Identifies/list down nursing diagnoses/problems
1.3 Utilizes a comprehensive total nursing care plan for assigned
patients
1.3.1 Plans nursing care considering the ff:
a. Patients comfort and safety
b. Priority problems
c. Medical care plan
d. Progress and response to treatment and nursing
care
1.3.2 Implements nursing interventions as planned
a. Demonstrates competence and confidence in
performing nursing u=interventions
b. Practices safety, comfort and privacy
c. Shows integrity in the implementation of standards
of nursing care
d. Acknowledges errors/mistakes as appropriate
e. Shows efficiency and economy of time and effort in
planning activities for the day
f. Implements discharge plans (home care,
medications compliance, intake precaution,
activities, follow up, diet regimen)
1.3.3 evaluates care rendered

2. Admits patient ensuring:

2.1 comfort and feeling of security
2.2 orientation to ward personnel, hospital set-up, policies and
various services
3. Establishes clear communications with nursing and other disciplines
regarding patient care:
3.1 confers with the physician regarding the
diagnosis/response/non-response to treatment
3.2 Initiates referrals as necessary
 3.3 Communicates with head nurse/nursing personnel regarding
patient care ( endorsements, nursing rounds, etc)
3.4 Confers with other members of the health team
4. Considers the 5 R’s in delegating functions
5. Records nursing care given
6. Ensures that the Kardex has completed entries at all times
7. Demonstrates nursing specific procedures as necessary
8. Guides others in the performance of nursing functions
9. Participates in nursing rounds/ bedside conferences
B. Demonstration of Professional and Personal Qualities
1. Identifies roles to patient, family and co-workers
2. Evaluates objectives for self-improvement
3. Shows consideration for the welfare of co-workers
4. Maintains harmonious relationship with unit personnel
5. Collaborates/communicates with the health team regarding unit
activities
6. Accepts delegated functions when necessary
7. Demonstrates situational flexibility and adaptability
8. Applies critical thinking in varied situations
9. Shows honesty and accuracy in data gathering, problem
identification, implementing interventions and evaluating outcomes
10. Identifies own capabilities and limitations
11. Accepts constructive criticisms and makes appropriate chnages
12. Avails self of learning opportunities
13. Follows policies and regulations of the hospital, unit and the college
of nursing
14. Reports to work punctually and regularly
15. Is neat and well groomed
16. Submits requirements on time
17. Is conscientious and with pleasant work attitude

Total Performance grade

Performance Grade x 70%

Computation for the performance grade:

Step 1: Rate the Staff Nurse from 1-4 where:

4 is very satisfactory: exhibits competency independently

3 is satisfactory: exhibits competency with minimum guidance
 2 is fair: exhibits competency with close supervision
1 needs improvement: did not exhibit competency
Step 2: to get the final grade for the above competency, compute the total score for items evaluated,
divide it by the highest total possible score for all items evaluated, multiply by 75, then add 25.

Example:
a. (165/172 x 75) + 25 = (0.96x75) + 25 =72 + 25 = 97. 0

Performance = 97 x .70 = 67.9

KNOWLEDGE: (20%)

1. Nursing care plan -----------------50% Knowledge = total grade x 20%

2. Case study --------------------------20%
3. Drug study --------------------------10% Knowledge:
4. Journal Readings ------------------10%
Other requirements --------------10%
5. Written Examinations ----------- 10 %

ATTITUDE/ATTENDANCE (10%)

1. Attitude ------------------------------5% Attitude = grade x 5%

2. Attendance --------------------------5% = x 0.05 =

Attendance = grade x 5%
= x 0.05 =

Attitude/ Attendance =

= Skills + Knowldege + Attitude/ Attendance

= + +
TOTAL GRADE =

Remarks:

Signature over Printed Name of Head Nurse Date