RLE EVALUATION CHECKLIST FOR GENERAL WARDS

(SURGERY, MEDICINE, AND PEDIA WARD)

Name:_______________________________ Group: ______ Date / Ward: _____________

Scoring: The Clinical Instructor will evaluate the student nurse using the following weights.
The RLE grade of the student nurse consists of SKILLS (50%), KNOWLEDGE (30%), and
PARTICIPATION (20%).

SKILLS (50%):The Clinical Instructor will write the corresponding score on the space provided, then
adds the score in each sub-task to compute for the total score in each task.

Please evaluate the student based on the following competencies listed below. Write the rating
on the space provided for each item using the following scale:

5 Competent The student performs consistently efficient and effective

4 Very Satisfactory
3 Satisfactory
2 Needs Improvement
1 Unacceptable
Task performance is done properly most of the times
The student’s performance is usually effective but not always
The student’s performance is consistently ineffective and
inefficient some time
The student’s performance is consistently ineffective and
inefficient most of the time

Tasks Sub-tasks Score

Documentation 1. Translates written orders into actions and nursing care
(15 points) 2. Able to follow-up previous orders, laboratory and diagnostic examinations.
(10%) 3. Demonstrate accuracy in recording/charting
TOTAL SCORE
1. Performs sufficient and adequate assessment relevant to the patient’s
Nursing immediate needs
Assessment 2. Formulates problems based on collected data
(25 points) 3. Prioritizes the problems identified in the assessment
(20%) 4. Demonstrates accuracy reporting significant findings and nursing diagnosis
5. Explains pathophysiological scheme of the identified problem
TOTAL SCORE
1. Implements rationalized nursing interventions with consideration for
patient’s safety, comfort and psychological well-being
Nursing Care 2. Monitors/Evaluates patient’s response/outcomes of care based on criteria
3. Administers medications using the principle of drug administration with
(30 points)
adequate knowledge and understanding of the pharmacology of the drugs
(20%)
4. Effectively performs monitoring of patient (I/O, V/S and GCS, etc)
5. Formulate a care of plan for priority nursing problems
6. Revise plan of care as needed
TOTAL SCORE

KNOWLEDGE (30%): The Clinical Instructor will utilize any of the following task as part of the
knowledge criteria.
1. QUIZ (Computation/Shifting Exam) (15%) : ____________

2. Output (Drug Study/NCP) (15%) : ____________

Altroy Van C. Agtang | NCC

 PARTICIPATION (20%): Please use the following scale in evaluating the student nurse in
participation.
5 The student exhibited the behavior all the time
4 The student exhibited the behavior most of the time
3 The student often exhibited the behavior
2 The student occasionally exhibited the behavior
1 The student never exhibited the behavior at all

Tasks (30 points) Score

1. Establishes good interpersonal relationship and communicates effectively with clients, family
and members of the health team
2. Accepts supervision and constructive criticism
3. Accepts responsibilities and shows interest on learning opportunities
4. Initiates and recognizes productive activities within the group
5.Always punctual in submitting requirements
6.Reports on time
SCORE

Computation for Final Grade:

Percentage Equivalent = % / PS x TRS

% Perfect Score Raw Score Rating

Documentation: 10 15
Nursing 20 25
Assessment
Nursing Care: 20 30
Quiz: 15
Output: 15
Participation: 20 20

Percentage Equivalent: ______

(Sum of all Rating)
Final Grade: ______
(PE/2+50)

Comments: _______________________________________________________________
_______________________________________________________________
_______________________________________________________________

________________________________
Name and Signature of Clinical Instructor

Altroy Van C. Agtang | NCC

 SUMMARY OF RLE GRADES

Year Level: ________ Group: _______ Schedule/ Ward: ___________________________________

le vauiEq ta enrcPe
15% 20 %

Final

ge
10% 20% 20% 15%
Grade
Name of Students

nt
Documen NSG Output Participa

Rating

Rating

Rating

Rating

Rating

Rating
NSG Care Exam tion
tation Assess (PS:
(30 pts) (PS: ___) (30 pts)
(15 pts) (25 pts) ___)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Prepared by: Verified by: Approved by:

___________________________________ Prof. Altroy Van C. Agtang RN, MAN Prof. Marnie U. Dela Cruz RN, MAN
Clinical Instructor Level Chair Dean, College of Nursing