NURSING PROGRAM

Performance Evaluation Checklist Competency

(Online RLE)
Testing for Blood Sugar (RBS)
Name of the Student: __________________________________________
Placement: _______________________
School Year: ______________________
Semester/ Term: S.Y. _________ First semester Second semester Summer

LEGEND
9-10 Competent Performs consistently in an effective manner
7-8 Progress Acceptable Performs effectively and efficiently with minimal
misses
5-6 Progress Moderately Performs efficiently with some misses
Acceptable
3-4 Progress Fairly Performs with more misses
Acceptable
1-2 Progress Poorly Acceptable Performs with lots of mistakes

PROCEDURE: 9-10 7-8 5-6 3-4 1-2

1. Checks the doctor’s order.
2. Washes hands.
3. Assembles all equipment and bring to bedside table.
4. Identifies the patient.
5. Explains the procedure to the patient/watcher.
6. Puts on the gloves.
7. Selects the puncture site (fingers, toes, heels).
8. Disinfects the site with cotton balls with alcohol. Allows to dry.
9. Turn on and set the glucometer to the appropriate code, e.g., code 9
10. Using the lancet, pricks the finger at the side.
11. Wipes away the first drop of blood if directed by the manufacturer.
12. Allows blood to fall on the appropriate portion of the reagent strip
until the back portion turns blue.
13. Applies pressure on the packed site with a dry cotton balls.
14. Inserts the reagent strip into the glucometer for reading.
15. Takes note of the reading; and confirms it with clinical instructor or
nurse on duty.
16. Removes gloves and discards used needle, cotton balls and strip to the
appropriate container.
17. Record time, result and patient’s response/s to the procedure.

_______________________________ __________________________
Signature Over Printed Name Signature Over Printed Name
Clinical Instructor Student