R.

04
GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
EVALUATION TOOL FOR NURSING CARE PLANS (HOSPITAL)

NAME ________________________________________ AREA ________________________________ DATE ________________

AREAS EXCELLENT GOOD FAIR POOR

4 3 2 1
Lists at least 5 subjective or objective data that List 3 -4 subjective or objective data that List 1 - 2 subjective or objective data that Unable to list subjective or objective data that
DATA COLLECTION should be collected when the diagnosis is present. should be collected when the diagnosis is should be collected when the diagnosis is should be collected when the diagnosis is
Background of the problem was clearly and present. Background of the problem was not present. Background of the problem was present. Background of the problem was not
correctly stated. well stated. incorrectly stated. stated.
NURSING DIAGNOSIS Diagnoses written correctly per NANDA format Written incorrectly without sufficient data to
with proper etiology &sufficient data to support support diagnosis
diagnosis
Goal is measurable, realistic, related to the Goal is not measureable, not realistic, not
problem; related to the problem;
Data supports if goal is met, not met with Data does not support if goal is met, not met
PLANNING/GOALS&
appropriate revisions with
EVALUATION
inappropriate revisions

Identified dependent, independent, collaborative Identified most dependent, independent, Identifies dependent, independent, Interventions were inappropriate and are not
IMPLEMENTATION & interventions appropriately; Scientific rationale is collaborative interventions appropriately; collaborative interventions with teaching; categorized as dependent, independent or
RATIONALE supported textbook citation Scientific rationale is somewhat relevant & Scientific rationale is not relevant &not collaborative.
[Evidence Base Information] supported with citation supported from textbook
[Evidence Base Information]
[Evidence Base Information]
Writing is totally free of grammar and spelling There are occasional grammar and spelling Grammar and spelling errors are frequent.
WRITING SKILLS errors. errors.
Hard to follow the ideas.
Clear and concise presentation of ideas. Clear presentation of ideas.
All references used are important and current; are Most of the references cited and listed are not No references cited
REFERENCES of good/scholarly quality. References are important and/or not of good/scholarly
correctly cited quality. References are not correctly cited and
listed.

NOTE: If the Nursing Diagnosis is incorrect, then only data collection & writing skills will be graded accordingly. Other criteria will be automatically garnering a grade of zero.

COMMENTS: ____________________________________________________________________________________________________________________________________________________________________________

CI’S NAME & SIGNATURE ____________________________

ME & SIGNATURE ____________________________
R.06

GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.

EVALUATION TOOL FOR ASSESSMENT OF PATIENT (WRITTEN)

NAME ________________________________________________ AREA _________________________________ DATE ________________

AREAS EXCELLENT GOOD FAIR POOR

4 3 2 1
GORDON’S 11 All of the data are organized and Most of the data are organized and There are patterns that are inappropriately All of the patterns were inappropriately
FUNCTIONAL HEALTH described correctly. Past and present described correctly. Past and present history organized and described. Past and present described
CARE PATTERNS history of the patient’s illness are of the patient’s illness are described history are incompletely described.
described exhaustively. superficially.

PHYSICAL ASSESSMENT All of the body systems/parts are Most of the body systems/parts are Some of the body systems/parts are Assessment of the body systems/parts
correctly and thoroughly assessed and correctly and thoroughly assessed and correctly and thoroughly assessed and are incomplete and incorrectly described.
described following the correct method of described following the correct method of described following the correct method of
assessment. assessment. assessment.

PRIORITIZATION All of the problems are correctly Most of the problems are correctly Only a few of the problems are correctly Problems were incorrectly prioritized.
prioritized based on Maslow’s Hierarchy prioritized based on Maslow’s Hierarchy of prioritized based on Maslow’s Hierarchy of
of needs or other methods of needs or other methods of prioritization. needs or other methods of prioritization.
prioritization.

Justification of the problems are all
JUSTIFICATION correctly stated and are based on related
literature.
Writing is totally free of grammar and
WRITING SKILLS spelling errors.
Clear and concise presentation of ideas.
All references used are important and
REFERENCES current; are of good/scholarly quality.
References are correctly cited.
Most of the justification of the problem are
correctly stated and are based on related
literature.
There are occasional grammar and spelling
errors.
Clear presentation of ideas.
Only a few were justified and are correctly Justification of the problem was based on
stated. Justification is based on related personal opinion.
literature.
There are more than occasional grammar Grammar and spelling errors are frequent.
and spelling errors.
Most ideas are presented clearly. Hard to follow the ideas.
Most of the references cited and listed are No references cited.
not important and/or not of good/scholarly
quality. References are not correctly cited
and listed.

COMMENTS: ______________________________________________________________________________________________________________________________________________

CI’S NAME AND SIGNATURE: _______________________

 R.07

GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.

RUBRICS FOR GRADING THE RECORD OF DAILY EXPERIENCE/LEARNING LOG

NAME ____________________________________________________ AREA ______________________________ DATE ________________

EXCELLENT GOOD POOR

3 2 1
KEY POINTS OF THE All events covered Most events covered but some missing A number of events missing
DAY/SUMMARY
Key ideas and main learning points explained in a Some ideas and main learning points explained Just a simple list of activities within the lessons
DEPTH OF COMMENT ON way that is easily understood and all points covered but not very easily understood or missing some
LESSON/S key points
Saying how you think the lesson has benefited your Saying how you felt about the lesson with some Saying how you felt about the lesson without saying
IMPACT ON PERSONAL learning referring to past knowledge and next steps explanation about how it helped you why (e.g. It was a good lesson for me)
LEARNING
The writing is generally free of grammar, spelling, The writing has some unedited errors such as The writing is full of unedited errors such as
and punctuation errors and makes very good sense grammar, spelling, and missing punctuation. It grammar, spelling and missing punctuation. It may
ACCURACY OF WRITING generally makes sense. also not make sense in places

COMMENTS: _________________________________________________________________________________________________________________

CI’S NAME AND SIGNATURE: ____________________________

Reference: Borromeo, Annabelle, RN, PhD, CNS

 R.09
GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
EVALUATION TOOL FOR DRUG STUDY (WRITTEN)

NAME_________________________________________________________ AREA _____________________________ DATE ________________

AREAS 0
Completely written all needed information Needed information about the drug is not Needed information about the drug is not all
CONTENT about the drug, data of patient is correct, all written, data of patient is not all correct, written, data of patient is incorrect, nursing
nursing responsibilities is related to the case nursing responsibilities is somewhat related responsibilities is not related to the case and to
and to the patient’s status. to the case and to the patient’s status. the patient’s status.
(4 points) (0 point)
(7 Points)
PRESENTATION OF PAPER Paper is neat, handwriting is legible Paper is neat, handwriting is not legible Paper is untidy, handwriting is not legible
(0 point)
(3 Points) (1 point)
COMMENTS: _______________________________________________________________________________________________________________________________________

CI’S NAME AND SIGNATURE: _______________________

 R.02
GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
EVALUATION TOOL FOR ORAL PRESENTATION (CASE CONFERENCE)

NAME ____________________________________ AREA ______________________ DATE ________________

AREAS EXCELLENT GOOD FAIR POOR

3 2 1 0
Very clear and concise flow of ideas. Clear flow of idea. Most ideas flow but focus is lost at Hard to follow the flow of ideas.
times.
Demonstrates passionate interest in Demonstrates interest in topic and Lack of enthusiasm and interest.
DELIVERY AND the topic and engagement with the engagement with the class. Limited evidence of interest in and
ENTHUSIASM class. engagement with the topic. Nervous tension obvious
Quick recovery from minor mistakes.
Relaxed, self – confident Some tension or indifference apparent
and possible
Visuals augmented and extended Use of visuals related to the material. Limited use of visuals loosely related No use of visuals.
VISUALS comprehension of the issues in to the material.
unique ways.
INVOLVEMENT OF Excellent and salient discussion Questions and discussion addressed Questions and discussion addressed Little or no attempt to engage the class in
THE CLASS: points out elucidated material to important information that developed surface features of the topic. learning.
 Questions develop deep understanding. understanding.
 Generating Limited use of activities to clarify
discussion Appropriate activities used to clarify understanding.
 Activities understanding
Excellent response to student Good response to class questions Satisfactory response to class Limited response to questions and discussion
RESPONSE TO comments and discussion with and discussion with some connection questions and discussion with limited with no reference to theory/research.
CLASS QUERIES appropriate content supported by made to theory/research reference to theory and research.
theory/research.
COMMENTS____________________________________________________________________________________________________________________________________________

CI’S NAME AND SIGNATURE: _________________________________

References: Rubrics for First and Biography by Stevens, Dannelle Ph.D. Sample Rubrics Packet

R.03
 GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
EVALUATION TOOL FOR GRADING THE MANUSCRIPT – REPORTING/HEALTH TEACHINGS/ CASE CONFERENCE

NAME _______________________________________ AREA ____________________________ DATE ________________

AREAS EXCELLENT GOOD FAIR POOR

3 2 1 0
Writing is totally free of grammar There are occasional grammar and There are more than occasional Grammar and spelling errors are
and spelling errors. spelling errors. grammar and spelling errors. frequent.
WRITING SKILLS
Clear and concise presentation of Clear presentation of ideas. Most ideas are presented clearly. Hard to follow the ideas.
ideas.
Makes realistic, appropriate, The discussion of the topic is Makes realistic or insightful The presented topic is not
CONTENTS substantial and insightful realistic and insightful but lacks in discussion of the topic. The appropriate nor realistic. Discussion is
explanation of the topic. substance. discussion is too short. too short and has no substance.

All references used are Some of the references cited and Most of the references cited and All of the references cited and listed
important and current; are of listed are important, some are of listed are not important and/or not are not important and/or not of
REFERENCES good/scholarly quality. good/scholarly quality. Some are of good/scholarly quality. good/scholarly quality. All references
References are correctly cited. correctly cited and listed. References are not correctly cited are not correctly cited and listed.
and listed.

COMMENTS: ______________________________________________________________________________________________________________________________________________

CI’S NAME AND SIGNATURE ______________________

References: Rubrics for First and Biography at www.servtech.com/public/germaine/rubric.html; Stevens, Dannelle Ph.D. Sample Rubrics Packet
 R.08
GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
EVALUATION TOOL FOR DRUG ADMINISTRATION (ACTUAL)

NAME __________________________________________________ AREA ___________________________ DATE ________________

DRUG ADMINISTRATION 1 0

DRUG PREPARATION Verifies the facts on the ticket against the doctor’s order and checked the MAR, Prepared medicines without checking the chart or materials are incomplete
prepares the complete materials needed and washed hands or failed to wash hands
Verified patient by:
 allowing client to state his/her name or
RIGHT PATIENT  checking arm band and room number and Failed to identify patient
 verified between 2 clients with the same last name
Checked medicine ordered is complete and legible, and compared the medicine Failed to check the chart or failed to compare the medicine ticket with the
RIGHT DRUG card/ticket with drug label 3Xand calculate and checked drug dose accurately drug label or failed to calculate and check drug dosage correctly
RIGHT DOSE
Drug/s was/were administered on the specified time considering drugs that will be Drugs were not administered on the specified time or the expiration of the
RIGHT TIME affected with food or patients’ activities and diagnostic procedures or policy of the medicine was not checked or given against the protocol of the institution
institution. Expiration date of the medicine is checked.

RIGHT ROUTE
RIGHT ASSESSMENT
RIGHT DOCUMENTATION
RIGHT EVALUATION
RIGHT EDUCATION
RIGHT TO REFUSE
UNDERSTANDING THE DRUG AND ITS EFFECT
COMMENTS: ________________________________________________________________________________________________________________________________________________________________
Ability of patient to swallow was checked before giving oral medicines and stayed with
the client until the medicine is swallowed. Medicines were administered at appropriate
route
Baseline data of patient was taken before the medication
Immediately recorded the needed information (signature, dose, route & etc.) using
correct symbols and abbreviations.
Noted the client’s response to medication
Explained to the patient why the medicine is given and what to expect after the medication.
Determined, when possible, reason for refusal and facilitated patient’ s compliance to medication and
explained risk for refusing meds & reinforced the reason for medication. CI was informed of the refusal and
refusal was documented immediately
Strong connections are made between the drug and its effects on body systems. Key
details are explained thoroughly.
Failure to administer the medicine at the appropriate route
Baseline data of patient was not taken before the medication
Failed to document the administered medication.
Failed to note client’s response to medication
Gave the medication without educating the patient.
Failed to determine, when possible, reason for refusal or failed to facilitate
patient’ s compliance to medication or failed to explain risk for refusing
meds or failed to reinforce the reason for medication or CI was not
informed of the refusal or refusal was not documented immediately
Little or no understanding of the drug and its effects on body systems.

GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
EVALUATION TOOL FOR PHYSICAL ASSESSMENT – ACTUAL
NAME: _________________________________________________________
EXCELLENT
AREAS
3 2
Identified and greeted the patient, explained the
procedure and identified personal needs ensuring
PREPARATION PHASE
privacy, has complete set of needed materials.
Asked the right questions by using open ended
questions, identifies the chief complaints, explores
current health status, notes the past and family history,
HISTORY TAKING handles special challenges (e.g., language barrier,
illiterate, confused, intoxicated, uncooperative, etc.)
Inspected each body system/ part using vision, smell,
and hearing. Observed for color, size, location,
INSPECTION movement, texture, symmetry, odors, and sounds. All of
the procedures were done correctly.
Touched patient utilizing different parts of the hands,
using varying degrees of pressure. Palpates areas
PALPATION appropriately. Procedures were done correctly.
Tapped fingers or hands quickly and sharply against
parts of the patient’s body, determined if an organ is
solid or filled with fluid or gas, considered organ’s
PERCUSSION
condition before initializing the procedure. Procedures
were done correctly.
Listened for various breath, heart and bowel sounds
with stethoscope, provided quite environment.
AUSCULTATION
Procedures were done correctly.
COMMENTS: ______________________________________________________________________________________________________________________
CI’s NAME & SIGNATURE: ________________________________________________________
AREA: _______________________________
GOOD
Identified and greeted the patient, explained the
procedure and identified personal needs when
reminded by the CI. Privacy was provided and
materials are complete.
Asked the right questions but used close ended
questions, identified the chief complaints, current
health status, past and family history is not
exhaustive, handles special challenges (e.g., language
barrier, illiterate, confused, intoxicated,
uncooperative, etc.)
Inspected each body system/ part using vision, smell,
and hearing. Observed for color, size, location,
movement, texture, symmetry, odors, and sounds.
Minimal (20 - 30%) errors were committed during the
conduct of the procedure.
Touched patient utilizing different parts of the hands,
using varying degrees of pressure. Palpates areas
appropriately. Minimal (20 - 30%) errors were
committed during the conduct of the procedure.
Tapped fingers or hands quickly and sharply against
parts of the patient’s body, determined if an organ is
solid or filled with fluid or gas, considered organ’s
condition before initializing the procedure. Minimal
(20 - 30%) errors were committed during the conduct
of the procedure.
Listened for various breath, heart and bowel sounds
with stethoscope, provided quite environment.
Minimal (20 - 30%) errors were committed during the
conduct of the procedure.
FAIR
1 0
Identified & greeted patient without proper
explanation. Privacy of patient was not
considered and materials are not complete.
Some of the questions asked were irrelevant,
identified the chief complaints, current health
status, past and family history were taken but
information is shallow, unable to handle special
challenges (e.g., language barrier, illiterate,
confused, intoxicated, uncooperative, etc.)
Inspected each body system/ part using vision,
smell, and hearing. Observed for color, size,
location, movement, texture, symmetry, odors,
and sounds. Most (more than 30%) of the steps
were erroneously done.
Touched patient utilizing different parts of the
hands, using varying degrees of pressure.
Palpates some areas inappropriately. Most
(more than 30%) of the steps were erroneously
done.
Tapped fingers or hands quickly and sharply
against parts of the patient’s body, determined if
an organ is solid or filled with fluid or gas,
sometimes considered organ’s condition before
initializing the procedure. Most (more than 30%)
of the steps were erroneously done.
Listened for various breath, heart and bowel
sounds with stethoscope, provided quite
environment. Most (more than 30%) of the steps
were erroneously done.
R.11
DATE: __________________
POOR
Proceeded immediately to the conduct of
physical assessment. Privacy of patient was
not considered and materials are not
complete.
Most of the questions asked were irrelevant,
identified the chief complaints, current health
status, past and family history were taken but
information is shallow, unable to handle
special challenges (e.g., language barrier,
illiterate, confused, intoxicated,
uncooperative, etc.)
Inspected some body systems/ parts using
vision, smell, and hearing. Minimally observed
for color, size, location, movement, texture,
symmetry, odors, and sounds. More than 40%
of the steps were erroneously done.
Touched patient utilizing limited parts of the
hands, using fewer varying degrees of
pressure. Palpates most areas
inappropriately. More than 40% of the steps
were erroneously done.
Tapped fingers or hands inadequately against
parts of the patient’s body, determined if an
organ is solid or filled with fluid or gas, did not
consider organ’s condition before initializing
the procedure. More than 40% of the steps
were erroneously done.
Listened for various breath, heart and bowel
sounds with stethoscope, quite environment
was not considered. More than 40% of the
steps were erroneously done.
R.14
 GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
EVALUATION TOOL FOR MINI/ GRAND CASE STUDY - HOSPITAL

NAME ____________________________________________________ AREA _____________________________ DATE ________________

 AREAS EXCELLENT
3 2
INTRODUCTION Related to the topic, backed up with
statistical data (International, National,
Local). Brief and concise. References are
properly cited. States the goal of choosing
the case.
All of the body systems/parts are correctly
PHYSICAL ASSESSMENT & and thoroughly assessed and described
GORDON’S following the correct method of
assessment. Analysis is based on related
literature. All of the Gordon’s category is
organized and described correctly and
exhaustively.
PROFILE OF THE PATIENT & All of the needed profile is complete and
HISTORY exhaustive. History is chronologically
arranged.
REVIEW OF ANATOMY & All of the Anatomy & Physiology is
PHYSIOLOGY/ discussed & illustrated exhaustively.
PATHOPHYSIOLOGY
COURSE IN THE WARD & Doctor’s orders were copied accurately and
DIAGNOSTIC TEST nursing responsibilities were cited
correctly. All carried out diagnostic tests
were evaluated properly & justified
correctly. References were correctly cited.
NURSING CARE PLAN Based on the prioritized problems. All
correctly justified, goal/ objectives are
SMART, all interventions are appropriate to
patient’s need supported by books/texts.
DRUG STUDY Completely written all needed information
about the drug, data of patient is correct,
nursing responsibilities is related to the
case and to the patient’s status
Makes realistic, exhaustive, appropriate
DISCHARGE PLANNING and insightful recommendations clearly
supported by the information presented.
Writing is totally free of grammar and
WRITING SKILLS spelling errors.
Clear and concise presentation of ideas.
GOOD
Most data given is related to the topic,
backed up with statistical data
(International, National, Local). Brief and
concise. Most references are properly
cited. States the goal of choosing the
case.
Most of the body systems/parts are
correctly and thoroughly assessed and
described following the correct method
of assessment. Analysis is based on
related literature. Most of the Gordon’s
category is organized and described
correctly and exhaustively.
Most of the needed profile is complete
and exhaustive. Most of the historical
data is chronologically arranged.
Most of the Anatomy & Physiology is
discussed & illustrated exhaustively.
Most of the Doctor’s orders were copied
accurately and most nursing
responsibilities were cited correctly.
Most of the carried out diagnostic tests
were evaluated properly & justified
correctly. References were correctly
cited.
Based on the prioritized problems. Most
are correctly justified, goal/ objectives
are SMART, most interventions are
appropriate to patient’s need supported
by books/texts.
Most of recommendations are realistic,
appropriate and insightful most are
clearly supported by the information
presented.
There are occasional grammar and
spelling errors.
Clear presentation of ideas.
FAIR
1 0
Some data given is related to the topic,
backed up with statistical data
(International, National, Local).
Circumstantial. Some references are
properly cited. Unable to state the goal
of choosing the case.
Some of the body systems/parts are
correctly and thoroughly assessed and
described following the correct method
of assessment. Analysis is based on
related literature. Some of the Gordon’s
category is organized and described
correctly and exhaustively.
Some of the needed profile is complete.
Some of the historical data is
chronologically arranged.
Some of the Anatomy & Physiology is
discussed & illustrated exhaustively.
Some of the Doctor’s were copied
accurately and some of the nursing
responsibilities were cited correctly.
Some of the carried out diagnostic tests
were evaluated properly & some have
missing justifications or are incorrectly
justified. References were correctly
cited.
Based on the prioritized problems. Some
are correctly justified, some goals/
objectives are not SMART, some
interventions are appropriate to patient’s
needs some are supported by
books/texts.
Needed information about the drug is
not all written, data of patient is not all
correct, nursing responsibilities is
somewhat related to the case and to the
patient’s status.
Some of the recommendations are
realistic, appropriate and insightful most
are clearly supported by the information
presented.
There are more than occasional grammar
and spelling errors.
Most ideas are presented clearly.
POOR
Very limited data to introduce the topic
and not backed up with statistical data
(International, National, Local).
Circumstantial. No reference were cited.
Goal of choosing the case was not
mentioned.
Assessment of the body systems/parts
are incomplete and incorrectly described.
Analysis is based on personal opinion.
Gordon’s category is disorganized ,
described incorrectly and incompletely.
Needed profile is incomplete. History is
chronologically arranged.
Anatomy & Physiology is not discussed
nor illustrated exhaustively. Unrelated to
the discussed case.
No data given for the Doctor’s orders. All
carried out diagnostic tests were NOT
evaluated.
Not based on the prioritized problems.
Incorrectly justified, goal/ objectives are
not SMART, interventions are
inappropriate to patient’s need and not
supported by books/texts.
Needed information about the drug is not
all written, data of patient is correct,
nursing responsibilities is not related to
the case and to patient’s status.
Irrelevant discharge planning
Grammar and spelling errors are
frequent.
Hard to follow the ideas.
COMMENTS: ___________________________________________________________________________________________________

CI’S NAME AND SIGNATURE: _______________________