STUDENT CLINICAL EVALUATION FORM

Name of Student Nurse:____________________________________ Year & Section: _____________

Criteria Date Date Date Date

5 – Excellent, 4 – Good, 3 – Fair, 2 – Poor, 1 – Very Poor Area Area Area Area
I. Attendance and Participation
a. Reports to the agreed area on time.
b. Secures complete supplies needed in the area.
c. Performs assigned nursing tasks effectively, efficiently
and safely.
d. Maintains a harmonious relationship with the patient,
family, peers, teacher and the health care team.
e. Presents oneself in a tidy and complete clinical uniform.
Total
II. Clinical Competency
a. Assesses the patient / the family utilizing various
appropriate assessment tools, methods and techniques.
b. Renders a safe and quality nursing care to the patient /
family.
c. Performs effective and efficient nursing interventions
guided by the nursing ethico-legal principles, standards
and the CDU-CN Values
d. Collaborates with the health care team in promoting
patient health, recovery, rehabilitation.
e. Documents relevant and accurate records and reports
as reflected on the monitoring sheets, focus charting
and etc.
Total
Evaluated by:
Name and Signature of Staff Nurse (use Trodat)
 III. Case Presentation
a. Presents a comprehensive nursing
assessment based on the patient condition.
b. Develops a Nursing Care Plan (NCP) and the
using the Brunswick Lens Model (BLM) and
evaluates its effectiveness
c. Provides a complete Drug Therapeutic Record
(DTR) of all prescribed medications and safely
administers these to the patient.
d. Produces a patient – centered Health
Teaching Plan (HTP) / Play Therapy
considering the different domains of learning.

Evaluated by:
Name and Signature of Clinical Teacher (use Trodat)

Remark:
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Record Adviser:

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