Republic of the Philippines

Cebu Normal University

Osmeña Blvd., Cebu City, 6000, Philippines

College of Nursing
Telephone No.: (+63 32) 254 4837
Email: cn@cnu.edu.ph
Website: www.cnu.edu.ph

Performance Rating Scale

_____ INTRAOPERATIVE MAJOR CIRCULATING

Name of Student: _________________________ Level and Section: __________

Instructions: Please rate the student’s performance as PERFORMED or NOT PERFORMED in the
competency column and write down your comments for any additional remarks.

A. PRELIMINARY PREPARATIONS
Performed Not Performed
Criteria Remarks
(1) (0)
1. Reports to the assigned OR after endorsement.
2. Cleans and disinfects the assigned operating
room.
3. Prepares the following:
3.1. Linen Pack
3.2. Instrument Set
3.3. Sutures
3.4. Paraphernalia
3.5. Equipment
4. Observes/Assists the circulating staff
nurse/clinical instructor in opening the pack or
drapes on the back-up table.
5. Assists the circulating staff nurse/institutional
worker in transferring the patient to the OR
table and ensures patient safety.
6. Ensures availability of patient’s chart and other
materials needed for the operation. Properly
endorsed to the circulating staff nurse.
7. Observes/Assists the circulating staff nurse in
complying with the surgical safety checklist. *
8. Documents pertinent and important information
regarding the patient and the case. *
9. Assists in tying the sterile gowns of the scrub
nurse and surgeons. *

Certification Date: 1 February 2021

Recertification due date: 24 January 2024
For verification of the certificate please
access www.gcl-intl.com (Certification Page 1 of 3
check and type the registration number)

Registration No. 52Q18778

 Republic of the Philippines
Cebu Normal University
Osmeña Blvd., Cebu City, 6000, Philippines

College of Nursing
Telephone No.: (+63 32) 254 4837
Email: cn@cnu.edu.ph
Website: www.cnu.edu.ph

10. Proceeds with first official counting together

with the circulating staff nurse and scrub nurse.
*
11. Anticipate the needs of the anaesthesiologist
for the induction of anaesthesia.
12. Documents induction of anaesthesia.
13. Observes/Assists the circulating staff
nurse/surgeon in performing skin preparation.
14. Assist circulating staff nurse in repositioning the
back-up table and mayo tray.
15. Observes/Assists the circulating staff nurse in
performing Surgical Time-Out. *
B. SURGICAL OPERATION
Performed Not Performed
Criteria Remarks
(1) (0)
1. Documents start of operation/cutting time.
2. Performs intraoperative official counting
together with the circulating staff nurse and
scrub nurse. *
3. Assist circulating staff nurse in adding sterile
materials. (if allowed)
4. Documents additional instruments and
paraphernalia added intraoperatively. *
5. Properly documents specimens. (if present) *
6. Maintains the sterility of materials and surfaces.
*
7. Properly handles sponges, materials and
instruments dropped on the floor.
8. Observes and documents the entire
intraoperative events. *
9. Anticipates the needs of the sterile team.
10. Performs final official counting together with the
circulating staff nurse and scrub nurse. *
11. Documents the end of the operation.
C. AFTER CARE
Performed Not Performed
Criteria Remarks
(1) (0)
1. Assists in untying the gowns of the sterile team.

Certification Date: 1 February 2021

Recertification due date: 24 January 2024
For verification of the certificate please
access www.gcl-intl.com (Certification Page 2 of 3
check and type the registration number)

Registration No. 52Q18778

 Republic of the Philippines
Cebu Normal University
Osmeña Blvd., Cebu City, 6000, Philippines

College of Nursing
Telephone No.: (+63 32) 254 4837
Email: cn@cnu.edu.ph
Website: www.cnu.edu.ph

2. Assists scrub nurse in gathering and sorting

instruments.
3. Assists circulating nurse/institutional worker in
transferring the patient from OR table to
stretcher, ensuring patient safety.
4. Assists circulating nurse/institutional worker in
transferring the patient from OR theatre to
PACU.
5. Assists in washing all the instruments used.
6. Assists soaking / oiling the instrument as
applicable
7. Thoroughly dries the instruments.
8. Arranges the instruments and places the
indicator.
9. Requests the circulating staff nurse to check
the instruments.
10. Ensures completeness of all pertinent and
necessary information for the case. *
Legend: * Critical competencies must be accomplished/performed. Failure to do so would mean a repeat performance for the student. The
inability to successfully pass the procedures will prevent them from assisting in the actual clinical duty and OR simulations (PRC required case).

Competent Advanced Beginner Novice

(86-100%) (70 – 85%) (<70%)
Description reflecting movement
Description reflecting achievement Description reflecting beginning
toward mastery level of
of mastery level of performance level of performance
performance
(Score of 35-40) (Score of 27 or less)
(Score of 28-34)
Performance of Items in the Performance of Items in the
Performance of Items in the
Procedural Checklist Procedural Checklist
Procedural Checklist

Total Score: ________ Description of Student’s Skill Competency: __________________________

Note: Students are expected to attain at least the level of being an advanced beginner for the case to be
credited as part of the PRC requirements. For OR simulations and actual clinical OR cases, kindly rate
procedures A to J.

_____________________________________
Signature and Name of Clinical Instructor

Certification Date: 1 February 2021

Recertification due date: 24 January 2024
For verification of the certificate please
access www.gcl-intl.com (Certification Page 3 of 3
check and type the registration number)

Registration No. 52Q18778