Document Code NSG-F0-00_

SAINT MARY’S UNIVERSITY Revision 00

Bayombong, Nueva Vizcaya, Philippines Effectivity Date 2022/07/01
Page/s 1 of 1
SCHOOL OF HEALTH AND NATURAL SCIENCES

Name: __________________________________________________________ Date: _________________ Group: _____________________

PERFORMANCE EVALUATION TOOL FOR HEADNURSING

0- Not Done 1 – Correctly Done

BEHAVIOR 0 1 REMARKS
A. PATIENT CARE (50%)
1. Categorizes degree of patient care required
2. Identifies priority problems of patients
3. Transmits plan of care to the rest of the nursing staff through
a. Verbal reminders
b. Kardex
c. Endorsements
4. Coordinates plan of care with the medical team, dietary department, physical
therapist, social worker, etc.
5. Ensures that new doctor’s orders are noted and carried out
6. Checks records
a. Kardex
b. Progress notes
c. Diet lists
d. Flow sheets
e. Ward reports
7. Makes rounds to observe effectiveness of care
8. Offers assistance to staff
9. Demonstrates nursing procedure
10. Concerning diagnostic work ups, supervises:
a. Preparation and/or sending of patients to diagnostic units
b. Collection and sending of specimen to appropriate places
11. Demonstrates competence and confidence in performing tasks
12. Displays competence in the use of the nursing process
13. Establishes clear communications with nursing and other disciplines regarding
patient care: the diagnosis-
a. Confers with the physician regarding the diagnosis/response/non response
to treatment/prognosis
b. Initiates referrals as necessary
c. Joins the physician’s rounds
d. Communicates with head nurse/nursing personnel regarding patient care
(endorsement, nursing rounds)
e. Confers with other members of the health care team
B. UNIT MANAGEMENT (15%)
1. Participates in patient/watcher orientation/education
2. Interprets hospital and ward policies to students, patients/families
3. Delegates tasks with consideration of abilities and skills
4. Evaluates completion of delegated tasks
5. Ensures the following:
a. Cleanliness of the area, adequacy of appropriate supplies, adequate
functioning of equipment
b. Checks attendance of personnel and makes the necessary adjustments
C. PERSONNEL MANAGEMENT (15%)
1. Conducts nursing rounds/bedside conference (at least once)
`2. Conducts staff development activities like sharing current relevant literature
with the staff
D. PROFESSIONAL AND PERSONAL QUALITIES (20%)
1. Accepts constructive criticisms and makes appropriate changes
2. Gives constructive criticisms
3. Demonstrates self-direction
 Document Code NSG-F0-00_
SAINT MARY’S UNIVERSITY Revision 00
Bayombong, Nueva Vizcaya, Philippines Effectivity Date 2022/07/01
Page/s 2 of 1
SCHOOL OF HEALTH AND NATURAL SCIENCES

4. Shows compassion and commitment to the welfare of the individual client and
family
5. Demonstrates honesty in date gathering, problem identification, implementing
interventions, and evaluating outcomes
6. Does the right thing despite consequences
7. Strives for continuous improvements of self -considering a holistic perspective
8. Pursues clients goals and objectives towards quality of life
9. Demonstrates critical thinking in varied situations
10. Demonstrates situational flexibility and adaptability
11. Integrates transcultural differences
12. Avails self-opportunities of learning
13. Sets objectives to direct activities
14. Follows policies and regulations of the hospital/ward/school
15. Utilizes a time plan for organization of activities/efficacy/economy of time and
energy
16. Maintains harmonious relationship with his/her staff and ward personnel
17. Reports to work punctually
18. Notifies ward if unable to report on duty
19. Appears neat and well groomed
20. Submits requirement on time
21.Displays consistency of one’s belief and actions

GRADING SYSTEM
Part A Total Score/48 x 65 + 35 x 50%
Part B Total Score/12 x 65 + 35 x 15%
Part C Total Score/4 x 65 + 35 x 15%
Part D Total Score/42 x 65 + 35 x 20%
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HEAD NURSING GRADE:_____________

Comments and Suggestions:

____________________________________________________________________________________________________________________________________
_____________________________________________________________________.

Clinical Instructor’s signature over printed name/ Date /time : ____________________________________________

Student’s signature over printed name / Date / Time: _______________________________________________________