JOSE RIZAL UNIVERSITY

College of Nursing and Health Sciences Performance

Checklist Bag Technique

Name of Student: Date: ___________

Year/Section/Group No.:201 N Grade: __________

Rate the student’s performance by checking the appropriate box using the following criteria:
5- Excellent (Carries out procedure efficiently, systematically and independently/ Personality trait is
observed at all times)
4- Very Satisfactory (Carries out procedure efficiently and systematically, requires minimal guidance and
supervision/ Personality trait is observed most of the time)
3- Satisfactory (Carries out procedure efficiently and systematically, requires moderate guidance and
supervision/ Personality trait is observed sometimes)
2- Fair (Carries out procedure with close guidance and supervision/ Personality trait is seldom observed)
1- Poor (Carries out procedure inefficiently and unsystematically/ Personality trait is never observed)

5 4 3 2 1
A. KNOWLEDGE – 30%
1. States objectives of this activity.
2. Uses appropriate terms.
3. States steps of the procedure in correct order.
4. Explains the rationale of every step.
B. SKILLS – 60%
1. Prepares plan of home visit following the prescribed format.
2. Identifies the client properly.
3. Introduces self and explains purpose of visit and procedure.
4. Place the bag on the table or any flat surface lined
paper/plastic lining, clean side out (folded part touching the
table). Put bag’s handles/strap under the bag.
5. Ask for a basin of water and a glass of water if faucet is not
available. Place these outside the work area.
6. Open the bag, take the paper/plastic lining and spread over
work field or area (the clean side out). The paper lining,
clean side out (folded part out).
7. Take out hand towel, soap dish and apron and place them
at one corner of the work area (within the confines of the
linen/plastic lining.)
8. Do hand washing. Wipe dry with towel. Leave the plastic 
wrappers of the towel and soap dish in the bag.

9. Put on apron right side out and wrong side with crease
touching the body, sliding the head into the neck strap.
Neatly tie the straps at the back.
10. Put out things most needed for the specific case and place
at one corner of the work area.
11. Place waste paper bag outside of the work area.
12. Close the bag.
13. Proceed to the specific nursing care or treatment.
14. After completing the nursing care or treatment, clean and
alcoholize the things used.
15. Do hand washing again.
2
16. Open the bag and put back all articles in their proper
places.
17. Remove the apron folding away from the body, with soiled
side folded inwards and the clean side out. Place it in the
bag.
18. Fold the linen/plastic lining; clean; place it in the bag and
close the bag.
19. Make post-visit conference on matters relevant to health
care, taking anecdotal notes preparatory to final reporting.
20. Make appointment for the next visit, taking note of the date,
time and purpose.
C. ATTITUDE -10%
1. Shows responsibility by having a complete set of equipment
needed in the activity and shows interest in doing the
procedure.
2. Displays courtesy and consideration in acknowledging
criticisms and suggestions by the Clinical Instructor.
3. Demonstrates integrity by doing the skill honestly,
competently and completely.
TOTAL

Knowledge / 20 x 60 + 40 = 91x .5= 48.5

Skills - / 100 x 60 + 40 = 88x .5= 44
TOTAL = 92.5=93

Clinical Instructor’s Comments / Suggestions:

Students’ Comments / Suggestions:

GACOT, CHRISTINE JOY TAJOR TEODORA MACALINCAG, RN, MPH

Student’s name & signature C.I.’s name & signature