Republic of the Philippines

NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY

College of Nursing and Allied Health Sciences
Brgy. Rizal, Sagay City, Negros Occidental
(034)722-4120, www.nonescost.edu.ph
ISO 9001:2015
Certified

NAME OF STUDENT _____________________________ CLINICAL AREA _______________________

INCLUSIVE DATE OF RLE EXPERIENCE _______________ GRADE _______________________________

CLINICAL PERFORMANCE RATING SCALE: HOSPITAL – BASED (ER, OPD and WARD)
(LEVEL IV)

Direction: Place the actual score if the behavior/skill described was demonstrated. If it was not
demonstrated include remarks in the space provided.

Behavior/Skill Score Remarks

D A
I. SAFE AND QUALITY NURSING CARE (SQC)
Applies the nursing process in the care of patients with problems of
nutrition and metabolism, perception and coordination, alterations in
immune response and infection, cellular aberration and
rehabilitation.
1.1 Assess the client’s health status based on:
 Nursing History 3
 Measures vital signs accurately 2
 Physical Assessment 3
 Diagnostic/Laboratory exams 2
1 .2 Analyzes client’s data utilizing the appropriate theoretical 2
framework.
1.3 Defines the nursing diagnosis 3
1.4 Prioritizes the nursing diagnosis 2
1.5 Formulates plan of care. 3
 Identifies Goals/Objectives 3
 Specifies appropriate nursing interventions 2
2
 Defines evaluation criteria
2
1.6 Implements appropriate interventions
3
 Health promoting interventions
3
 Illness preventing interventions 2
 Curative/restorative interventions 2
 Supportive biobehavioral interventions 2
 Rehabilitative interventions 4
 Interventions specific to the nursing diagnosis identified 3
 Observes principles for safety, privacy and comfort when providing
care. 2
 Gives full attention to patient/client when giving care. 3
 Provides nursing care based on the individual’s needs 2

II.MANAGEMENT OF RESOURCES, ENVIRONMENT AND

EQUIPMENT (MRE)

 Adapts environment to make it conducive for healing/pleasing of the

patient. 2
III. HEALTH EDUCATION (HE)
 Provides appropriate health education and health teachings 2

IV. LEGAL RESPONSIBILITIES (LR)

 Maintains confidentiality of patient/client and staff. 2
 Safeguards the individual’s rights to privacy 1
 Prevents and/or manages problems related with specific phase of
the nurse – client relationship. 1
V. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
Demonstrates positive attitudes by:
5.1 Observes bedside manners and courtesies. 1
5.2 Respects client’s spirituality and cultural needs. 1
 5.3 Demonstrates honesty in reporting/recording data. 2
5.4 Demonstrates compassion, genuine concern for patient’s welfare,
and caring not only for patient but also to the family/support system. 2
5.5 Presents self in a manner that promotes the image of nursing.
 Well groomed 1
 Pleasant disposition 1

VI. QUALITY IMPROVEMENT (QI)

 Evaluates client’s response/outcomes of care based on criteria 3
 Uses feedback/clinical supervision to improve nursing care. 2
 Shows how feelings/reactions can be managed to maintain
standards of care. 2
 Uses an updated review of literature in:
- Developing the nursing care plan.
- Ward conference/Case presentation 2

VII. ETHICO-MORAL RESPONSIBILITIES (EMR)

Displays self direction and self – discipline
 Reports for duty on time. 1
 Submits requirements on time. 1
 Finishes work on time. 1
 Shows initiative in activities. 2
 Demonstrates effective time management 2
 Demonstrates honesty in reporting/recording data. 2

VIII. RESEARCH
 Proposes possible solutions/options to problems/issues identified
utilizing research studies 2

IX. RECORD MANAGEMENT (RM)

 Demonstrates accuracy and honesty in recording and reporting. 2

X. COMMUNICATION
 Demonstrates therapeutic communication skills. 2
 Introduces self and addresses patients/clients, other individuals as
they prefer to be addressed. 1
 Treats others with respect regardless of background. 1

XI. COLLABORATION AND TEAMWORK

Shows leadership in caring for the patients by:
 Collaborates with members of the health team involved in client 2
care
 Initiates activities or interventions to promote/maintain health of
prevent illness. 2
 Supports the rights of other providers to suggest alternatives to
the plan of care. 1

TOTAL SCORE 100

GRADE EQUIVALENT

Comments: ________________________________________________________

Signature of Student: ______________________

Signature of Teacher: _____________________

Date of Evaluation: _______________________

 Republic of the Philippines
NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY
College of Nursing and Allied Health Sciences
Brgy. Rizal, Sagay City, Negros Occidental
(034)722-4120, www.nonescost.edu.ph
ISO 9001:2015
Certified

NAME OF STUDENT _____________________________ CLINICAL AREA _______________________

INCLUSIVE DATE OF RLE EXPERIENCE _______________ GRADE _______________________________

CLINICAL PERFORMANCE RATING SCALE: HOSPITAL – BASED (OPD and WARD)

(LEVEL III)

Direction: Place the actual score if the behavior/skill described was demonstrated. If it was not
demonstrated include remarks in the space provided.

Behavior/Skill Score Remarks

D A
I. SAFE AND QUALITY NURSING CARE (SQC)
Applies the nursing process in the care of patients with problems of
nutrition and metabolism, perception and coordination, alterations in
immune response and infection, cellular aberration and
rehabilitation.
1.1 Assess the client’s health status based on: 3
 Nursing History 2
 Measures vital signs accurately 3
 Physical Assessment 2
 Diagnostic/Laboratory exams 2
1 .2 Analyzes client’s data utilizing the appropriate theoretical
framework. 3
1.3 Defines the nursing diagnosis 2
1.4 Prioritizes the nursing diagnosis 3
1.5 Formulates plan of care. 3
 Identifies Goals/Objectives 2
 Specifies appropriate nursing interventions 2
2
 Defines evaluation criteria
3
1.6 Implements appropriate interventions
3
 Health promoting interventions
2
 Illness preventing interventions 2
 Curative/restorative interventions 2
 Supportive biobehavioral interventions 4
 Rehabilitative interventions 3
 Interventions specific to the nursing diagnosis identified
 Observes principles for safety, privacy and comfort when providing 2
care.
 Gives full attention to patient/client when giving care. 3
 Provides nursing care based on the individual’s needs 4

II. HEALTH EDUCATION (HE)

 Provides appropriate health education and health teachings 2

III. LEGAL RESPONSIBILITIES (LR)

 Maintains confidentiality of patient/client and staff. 2
 Safeguards the individual’s rights to privacy 1
 Prevents and/or manages problems related with specific phase of
the nurse – client relationship. 1

IV. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)

Demonstrates positive attitudes by:
5.1 Observes bedside manners and courtesies. 1
5.2 Respects client’s spirituality and cultural needs. 1
5.3 Demonstrates honesty in reporting/recording data. 2
5.4 Demonstrates compassion, genuine concern for patient’s welfare,
 and caring not only for patient but also to the family/support system. 2
5.5 Presents self in a manner that promotes the image of nursing.
 Well groomed 1
 Pleasant disposition 1

V. QUALITY IMPROVEMENT (QI)

 Evaluates client’s response/outcomes of care based on criteria 3
 Using feedback/clinical supervision to improve nursing care. 2
 Shows how feelings/reactions can be managed to maintain 2
standards of care.
 Uses an updated review of literature in:
- Developing the nursing care plan. 2
- Ward conference/Case presentation

VI. ETHICO-MORAL RESPONSIBILITIES (EMR)

Displays self direction and self – discipline
 Reports for duty on time. 1
 Submits requirements on time. 1
 Finishes work on time. 1
 Shows initiative in activities. 2
 Demonstrates effective time management 2
 Demonstrates honesty in reporting/recording data. 2

VII. RESEARCH
 Proposes possible solutions/options to problems/issues identified 2
utilizing research studies

VIII. RECORD MANAGEMENT (RM)

 Demonstrates accuracy and honesty in recording and reporting. 2

IX. COMMUNICATION
 Demonstrates therapeutic communication skills. 2
 Introduces self and addresses patients/clients, other individuals as
they prefer to be addressed. 1
 Treats others with respect regardless of background. 1

X. COLLABORATION AND TEAMWORK

Shows leadership in caring for the patients by:
 Collaborates with members of the health team involved in client
care 2
 Initiates activities or interventions to promote/maintain health of
prevent illness. 2
 Supports the rights of other providers to suggest alternatives to
the plan of care. 1

TOTAL SCORE 100

GRADE EQUIVALENT

Comments: ________________________________________________________

Signature of Student: ______________________

Signature of Teacher: _____________________

Date of Evaluation: _______________________

 Republic of the Philippines
NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY
College of Nursing and Allied Health Sciences
Brgy. Rizal, Sagay City, Negros Occidental
(034)722-4120, www.nonescost.edu.ph
ISO 9001:2015
Certified

NAME OF STUDENT _____________________________ CLINICAL AREA _______________________

INCLUSIVE DATE OF RLE EXPERIENCE _______________ GRADE _______________________________

CLINICAL PERFORMANCE RATING SCALE: HOSPITAL – BASED (WARD)

(LEVEL II)

Direction: Place the actual score if the behavior/skill described was demonstrated. If it was not
demonstrated include remarks in the space provided.

Behavior/Skill Score Remarks

D A
I. SAFE AND QUALITY NURSING CARE (SQC)
Applies the nursing process in the care of patients with problems of
nutrition and metabolism, perception and coordination, alterations in
immune response and infection, cellular aberration and
rehabilitation.
1.1 Assess the client’s health status based on:
 Nursing History 3
 Measures vital signs accurately 2
 Physical Assessment 3
 Diagnostic/Laboratory exams 2
1 .2 Analyzes client’s data utilizing the appropriate theoretical
framework. 2
1.3 Defines the nursing diagnosis 3
1.4 Prioritizes the nursing diagnosis 2
1.5 Formulates plan of care. 3
 Identifies Goals/Objectives 3
 Specifies appropriate nursing interventions 2
2
 Defines evaluation criteria
2
1.6 Implements appropriate interventions
3
 Health promoting interventions
3
 Illness preventing interventions 2
 Curative/restorative interventions 2
 Supportive biobehavioral interventions 2
 Rehabilitative interventions 4
 Interventions specific to the nursing diagnosis identified 3
 Observes principles for safety, privacy and comfort when providing
care. 2
 Gives full attention to patient/client when giving care. 3
 Provides nursing care based on the individual’s needs 4

II. HEALTH EDUCATION (HE)

 Provides appropriate health education and health teachings 2

III. LEGAL RESPONSIBILITIES (LR)

 Maintains confidentiality of patient/client and staff. 2
 Safeguards the individual’s rights to privacy 1
 Prevents and/or manages problems related with specific phase of
the nurse – client relationship. 1
IV. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
Demonstrates positive attitudes by:
5.1 Observes bedside manners and courtesies. 1
5.2 Respects client’s spirituality and cultural needs. 1
5.3 Demonstrates honesty in reporting/recording data. 2
5.4 Demonstrates compassion, genuine concern for patient’s welfare,
and caring not only for patient but also to the family/support system. 2
 5.5 Presents self in a manner that promotes the image of nursing.
 Well groomed 1
 Pleasant disposition 1

V. QUALITY IMPROVEMENT (QI)

 Evaluates client’s response/outcomes of care based on criteria 3
 Using feedback/clinical supervision to improve nursing care. 2
 Shows how feelings/reactions can be managed to maintain 2
standards of care.
 Uses an updated review of literature in:
- Developing the nursing care plan. 2
- Ward conference/Case presentation

VI. ETHICO-MORAL RESPONSIBILITIES (EMR)

Displays self direction and self – discipline
 Reports for duty on time. 3
 Submits requirements on time. 3
 Finishes work on time. 1
 Shows initiative in activities. 2
 Demonstrates effective time management 2
 Demonstrates honesty in reporting/recording data. 2

VII. COMMUNICATION
 Demonstrates therapeutic communication skills. 2
 Introduces self and addresses patients/clients, other individuals as
they prefer to be addressed. 1
 Treats others with respect regardless of background. 1

VIII. COLLABORATION AND TEAMWORK

Shows leadership in caring for the patients by:
 Collaborates with members of the health team involved in client
care 2
 Initiates activities or interventions to promote/maintain health of
prevent illness. 2
 Supports the rights of other providers to suggest alternatives to
the plan of care. 1

TOTAL SCORE 100

GRADE EQUIVALENT

Comments: ________________________________________________________

Signature of Student: ______________________

Signature of Teacher: _____________________

Date of Evaluation: _______________________

 Republic of the Philippines
NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY
College of Nursing and Allied Health Sciences
Brgy. Rizal, Sagay City, Negros Occidental
(034)722-4120, www.nonescost.edu.ph
ISO 9001:2015
Certified

NAME OF STUDENT ______________________________ CLINICAL AREA_____________________

INCLUSIVE DATE OF EXPERIENCE __________________ GRADE ____________________________

PERFORMANCE EVALUATION CHECKLIST

(HOSPITAL EXPERIENCE – ALL LEVELS)
Medical – Surgical Nursing

Direction: Encircle the score if the behavior/skill was demonstrated. Indicate remarks, as needed.

BEHAVIOR/SKILL SCORE REMARKS

I. SAFE AND QUALITY NURSING CARE (SQC)

 Assess health status. 2
 Performs physical examination 5
 Correctly 5
 With confidence 10
 Differentiates between normal and abnormal findings 10
 Detects abnormalities in vital signs
10
 Determines the significance of laboratory and diagnostic
findings to the current problems.
 Picks out critical and essential data in nursing history
relevant to current situation.
10
 Identifies nursing diagnosis in a systematic manner 10
 Nursing diagnosis reflect human response
 Nursing diagnosis reflect conditions primarily resolved by 10
nursing intervention or therapy. 10
 Nursing diagnosis reflect etiology as the focus of treatment
 Correlates between PE findings, nursing history, 10
diagnostic/lab exam results. 10
 All existing nursing diagnosis are identified.
 Nursing diagnosis specifies the defining characteristics. 5
Prioritizes nursing diagnosis 10
 Formulates care plan for priority nursing problem. 10
 Determines the outcome criteria 2
 Selects appropriate nursing actions
 Anticipates needs for future care vis a vis potential
problem. 5
 Implements care plan with the client 5
 Develops the self – management capability of the client 5
 Ensures safety, comfort, privacy in rendering care 5
 Provides necessary curative measures e.g. airway
maintenance and oxygenation, correct drug administration,
corrects fluid and electrolyte imbalance and administers
blood component, provides peri – operative care.
5
 Implements the plan of care jointly with the client.
5
 Performs nursing procedures/activities 5
 With ease and confidence 5
 Correctly 5
 Systemically 5
 Provides after care 5
 Revises care plan as needed
II. MANAGEMENT OF RESOURCES AND ENVIRONMENT (MRE)
 Utilizes available physical & professional resources 2
 Utilizes biobehavioral strategies (e.g. mind-body-spirit
paradigm & reflective of holism) 5
III. HEALTH EDUCATION (HE)
 Involves the client in the details of the plan, as appropriate 5
 Provides health teachings about restorative/rehabilitative measures e.g. dietary 5
regimen, prescribed exercises, lifestyle modification

5
IV. LEGAL RESPONSIBILITIES (LR)
 Shows commitment to the welfare of the client

V. ETHICO – MORAL RESPONSIBILITIES (EMR)

 Demonstrates core value. 2
 Shows honesty in data gathering, problem identification,
implementing interventions, reporting, recording and
evaluating outcomes. 2
 Manifests consistency in beliefs and actions. 2
 Shows sensitivity to social problems affecting the health 2
status of the clientele being served.
 Considers the ethnic orientation of the client/family 2
 Displays critical thinking in the analysis of the health 2
problems of the client/family. 2
2
 Practices bioethical principles in care
2
 Treats client with respect
2
 Maintains fidelity 2
 Safeguards the right to privacy e.g. confidentiality and family
 Shows compassion for the client and family 2
 Demonstrates gender sensitivity in care 2
 Considers a holistic perspective of the client 2
 Demonstrates situational flexibility and adaptability 2
 Models good health habit
VI.PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD
 Demonstrates attributes of a future professional 2
 Shows awareness of own feelings and reactions and their
effect on family/client. 2
 Accepts suggestion and constructive criticisms 2
 Manifests self direction 2
 Reports for duty/conference/consultation on time 2
 Submits requirements on time 2
2
 Shows initiative in activities
2
 Utilizes teacher’s supervision effectively
2
 Discusses difficulties encountered 2
 Seeks closer supervision when needed 10
 Shows active participation in group conferences/ward
classes.
VII. QUALITY IMPROVEMENT (QI) 10
 As appropriate, evaluates plan of care, with client using the outcome criteria.
 Accepts suggestion and constructive criticisms
2
VIII. RESEARCH (R) 10
 Utilizes research studies in implementing care
IX. RECORD MANAGEMENT (RM)
 Performs accurate documentation and recording 10
 Data is accurate 10
 Data is complete 5
 Shows honesty in documentation 5
 On time 4

X. COMMUNICATION
 Establishes rapport with the client 2
 Addresses client with preferred name 2

XI. COLLABORATION AND TEAMWORK (CTM) 2

 Coordinates with the other member of the health team
TOTAL SCORE 368
 GRADE EQUIVALENT

Comments: ________________________________________________________

Signature of Student: ______________________

Signature of Clinical Instructor: ______________________

Date of Evaluation: ________________________