Questionnaire

Name (optional):

Age:

Sex:

Name of hospital:

Public: ___ Private: ___

3- ALWAYS 2- SOMETIMES 1- NEVER N/A- NOT APPLICABLE

PERFORMANCE SCORE
I. DUTIES AND FUNCTIONS
A. ASSESSMENT
1. Establish rapport with patient/client

2.Utilize various assessment techniques to determine patient’s

condition, problems and needs

a. Completes and uses nursing health history and assessment

worksheet on admission.

b. Performs simple physical examinations.

c. Involves patient, family and other significant others in obtaining
accurate information.
d. Assesses client and family’s capability to participate in patient
care.
3. Reviews past and present medical records to identify patterns of
illness and coping abilities.
4. Synthesizes significant laboratory findings.
5.Validates and organizes collected data focusing functions needing
assistance/support.
6. Analyzes and interprets collected data.
7.Formulates Nursing Diagnosis
B. PLANNING FOR PATIENT CARE
1. Establishes priorities of nursing diagnosis.
2. Mutually formulates goals and expected outcome with patient, family,
and SO.
3. Collaborates/coordinates with health team members in planning for
patient care.
4. Correlates nursing care plan with medical plan of care.
5. Selects appropriate nursing interventions/ strategies/actions.
6. Develops alternatives in plan of care.

7. Writes the nursing care plan

8. Updates and modifies the plan as needed.
C. IMPLEMENTATION OF NURSING CARE PLAN
1. Performs nursing procedures accurately, completely and safely.
a. Observes the 7 rights in administering medicines.
b. Provides/assists in performance of activities of daily living
whenever needed.
c. Prepares patients for special procedures and assists wherever
needed.
d. Uses precautionary and preventive measures in providing care
 e. Assists patients in meeting emotional and spiritual needs.
2. Provides and maintains therapeutic environment.

a. motives patient to adhere to treatment regimen

b. Adjusts care in accordance with patients need.
c. Orients patient/family/SO to hospital.
3.Reassures patient to determine whether a remodification of care plan
is necessary.
4. Modifies the nursing care plan as needed.
5. Provides health teachings to patient/family or SO.
6.Conducts discharge planning with patient/family SO and members of
health team.
7. Coordinates/collaborates with various members of the health tea,
divisions of the hospital for smooth functioning of units and harmonious
relationships.
8. Documents nursing interventions completely, accurately and on time.
9. Maintains confidentiality of records.
10. Acts as patients advocate whenever needed.
D.EVALUATION OF NURSING INTERVENTION
1. Monitors patient’s clinical status throughout tour of duty.

2. Resets priority of care according to patient’s condition and needs.

3. Evaluates the efficiency and effectiveness of nursing intervention
rendered.
4. Adjust plan of care according to changing health needs of patient
5. Participates in quality assurance programs of units.
II. PROFESSIONALISM AND SERVICE COMMITMENT
1. Belongs to professional organizations.
2. Neat and well groomed. Adheres to Dress Code.
3. Punctual in reporting for duty.
4. No unexplained/ unexcused absences nor undertimes.

5. Courteous, tactful in dealing with clients and relatives.

6. Has smooth relationships with peers, superiors and co workers.
7. Participates in Nursing committees, research studies and other
activities that promote advancement in nursing practice and patient care.
8. Honest in work and in dealing with others.
9. Ready and willing to perform other responsibilities that may be
delegated to her/him.
J. Takes responsibility for own professional growth and development
through formal and informal means.