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STAFF NURSE PERFORMANCE EVALUATION SHEET Name: ___________________________________________________ Date: __________________ Position: _____________________________________ Performance Period: __________________ This

evaluation aims to appraise the performance of the staff nurse in his/her assigned area at a given period of time. The 11 key areas of responsibility of a nurse divided into 4 parts which are the core competencies for nursing practice in the Philippines is the basis for evaluation. Put a Check ( ⁄ ) mark on the appropriate box for each item. Scoring guide: 5- Always 2- Seldom

4- Most of the time 1- Never

3- Sometimes N/A- Not Applicable

PART 1 PATIENT CARE COMPETENCIES A cluster of key areas of responsibility which serves as the core of competencies which includes safe and quality care, communication, collaboration and teamwork and health education. I. 1. SAFE AND QUALITY NURSING CARE 1 2 3 4 5

Demonstrates knowledge base on the health /illness status of individual a. Identifies the health needs of the patients /groups b. Explains the health status of the patients /groups

2. Provides sound decision making in the care of individuals / groups considering their beliefs and values a. Identifies the problem b. Gathers data related to the problem c. Analyses the data gathered d. Selects appropriate action e. Monitors the progress of the action taken 3. Promotes safety and comfort of patients a. Performs age-specific safety measures in all aspects of patient care b. Performs age-specific comfort measures in all aspects of patient care Sets priorities in nursing care based on patients’ needs a. Identifies the priority needs of patients b. Analyses the needs of patients c. Determines appropriate nursing care to be provided Ensures continuity of care a. Refers identified problem to appropriate individuals / agencies b. Establishes means of providing continuous patient care

4.

5.

6. Administers medications and other health therapeutics a. Conforms to the 10 golden rules in medication administration and health therapeutics 7. Utilizes the nursing process as framework for nursing 7.1 Performs comprehensive and systematic nursing assessment a. Obtains consent b. Completes appropriate assessment forms c. Performs effective assessment techniques d. Obtains comprehensive client information e. Maintains privacy and confidentiality f. Identifies health needs

family. Provides “ Holding” or emergency numbers for services TOTAL = 5.2 Formulates a plan of care in collaboration with patients and other members of the health team a. email and internet. Implements nursing intervention that is safe and comfortable c. Accomplishes patient centered discharge plan 7. Implements immediate and appropriate intervention TOTAL = COMMENTS:_________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ II. Revises care plan when necessary 8.4 Evaluates progress toward expected outcomes a. his family before carrying them out b. group and community a. Readily smiles Uses appropriate information technology to facilitate communication a. Utilizes telephone. Listens attentively to client’s queries and requests c. touch. Explains interventions to patients. mobile phone.7. Responds to needs of individuals. Acts according to clients’ health condition and needs d. Provides reassurance through therapeutic. Includes patient and his family in care planning b. COMMUNICATION 1 2 3 4 5 Establishes rapport with patients. 1. COMMENTS:_________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ . Spends time with the client to facilitate conversation that allows client to express concerns 2. Interprets and validates client’s body language and facial expression 3. Identifies sudden changes in the patient’s health conditions b. Monitors effectiveness of nursing interventions b. Develops comprehensive patient care plan d. States expected outcomes of nursing intervention c. Utilizes formal and informal channels a. significant others and members of the health team a.3 Implements planned nursing care to achieve identified outcomes a. Identifies verbal and non-verbal cues a. and informatics b. warmth and comforting words of encouragement b. Creates trust and confidence b. Performs nursing activities effectively and in a timely manner 7. Identifies significant others so that follow up care can be obtained c. Responds to the urgency of the patient’s condition a. Makes use of available visual aids 4.

facial expression and gestures e. Revises health education plan when necessary 4. Provides reassuring presence through active listening. family. touch. Obtains learning info. Contributes to decision making regarding patients’ needs and concerns b. 1. Involves the patient. through interview. Documents outcome of care c. Completes assessment records appropriately d. Develops learning materials for health education a. Utilizes appropriate strategies d. Refers patients to allied health team partners b. Identifies priority needs 2. Provides for feedback to finalize the plan Implements the health education plan a. teachinglearning resources and evaluation parameters c. Considers client and family’s preparedness c. Utilizes evaluation parameters b. Defines relevant information c. Considers nature of learner in relation to: social. educational and religious factors. time allotment. HEALTH EDUCATION 1 2 3 4 5 Assesses the learning needs of the patient and family a. Acts as liaison / advocate of the patient c. significant others and other resources b. Respect the role of other members of the health team e. Prepares accurate documentation for efficient communication of services TOTAL = COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ IV. 5. TOTAL = COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ . colleagues and other members of the health team 2. Formulates a comprehensive health education plan with the following components: objectives. 3. Establishes collaborative relationship with colleagues and other members of the health team a. COLLABORATION AND TEAMWORK 1 2 3 4 5 1. Maintains good interpersonal relationship with patients. Recommends appropriate intervention to improve patient care d. political.III. Collaborates plan of care with other members of the health team a. content. cultural. Provides for a conducive learning situation in terms of time & place b. Monitors client and family’s responses to health education Evaluates the outcome of health education a. Develops health education plan based on assessed & anticipated needs a. Participates actively in patient care management including audit c. observation & validation b. economic.

Complies with required continuing professional education e. privacy. mission of the institution where one belongs b. Reports unethical and immoral incidents to proper authorities = 3. etc. TOTAL COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ .e. Acts in accordance with the terms of contract of employment and other rules and regulations d. 3. Justifies basis for nursing actions and judgment c. a. LEGAL RESPONSIBILITY 1 2 3 4 5 Adheres to practices in accordance with the nursing law and other relevant legislation including contracts. informed consent. Utilizes appropriate patient care records and reports. TOTAL COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ VI. Checks the completeness of informed consent and other legal forms Adheres to organizational policies and procedures. Secures waiver of responsibility for refusal to undergo treatment or procedure g.PART 2 EMPOWERING COMPETENCIES A cluster of key areas of responsibility that mandate compliance to the standards of legal. Meets nursing accountability requirements as embodied in the job description b. Accomplishes accurate documentation in all matters concerning patient care in accordance to the standards of nursing practice. Holds current professional license c. Articulates the vision. Projects a positive image of the profession Adheres to the national and international code of ethics for nurses a. Fulfils legal requirements in nursing practice b. Acts in accordance with the established norms of conduct of the institution / organization Documents care rendered to patients a. V. = 2.) 2. b. ethico-moralspiritual responsibilities and personal and professional development. 1. Respects the rights of individual / groups a. Adheres to the Code of Ethics for Nurses and abides by its provision b. Renders nursing care consistent with the patient’s bill of rights: (i. confidentiality of information. ETHICO-MORAL RESPONSIBILITY 1 2 3 4 5 1. local and national a. Confirms information given by the doctor for informed consent f. Accepts responsibility and accountability for own decision and actions a.

Explains current nursing practices. Utilizes a records system ex. when situations call for it 2. Determines personal and professional goals and aspirations Pursues continuing education a. 4. without proper authority. TOTAL = COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ PART 3 ENABLING COMPETENCIES A cluster of key areas of responsibility that provide support to the effective & efficient performance of the patient care competencies which includes management of resources & environment & records management.VII. 5. c. Maintains accurate and updated documentation of patient care a. weaknesses. TOTAL = COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 1 2 3 4 5 . and religious activities b. Listens to suggestions and recommendations b. Observes confidentially and privacy of the patient’s records. RECORDS MANAGEMENT 1. Kardex 3. Maintains an organized system of filing and keeping patients’ records in a designated area. Tries new strategies or approaches c. limitations b. Demonstrates good manners and right conduct at all times b. Sets attainable objectives to enhance nursing knowledge and skills c. civic. Participates in formal and non-formal education b. 3. Records outcome of patient care a. VIII. Adapts to changes willingly Performs function according to professional standards a. Behaves appropriately at all times Possesses positive attitude towards change and criticism a. Dresses appropriately c. 2. Completes updated documentation of patient care. PERSONAL AND PROFESSIONAL DEVELOPMENT 1 2 3 4 5 Identifies own learning needs a. Refrains from releasing records & other info. Maintains membership to professional organizations c. Verbalizes strengths. Observes legal imperatives in record keeping a. Support activities related to nursing and health issues Projects a professional image of the nurse a. b. social. Demonstrates congruence of words and action d. Participates actively in professional. 1. Applies learned information for the improvement of care Gets involved in professional organizations and civic activities a. Assesses own performance against standards of practice b. 6.

TOTAL = COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ PART 4 ENHANCING COMPETENCIES A cluster of key areas of responsibility that ensures excellent performance of the patient care competencies which includes research and quality improvement. Refers malfunctioning equipment to appropriate unit Checks proper functioning of equipment a. Documents and records all nursing care and actions e. Actively contributes relevant information of patients during rounds thru readings and sharing with others . 1. 3. Observes proper disposal of wastes b. Shares with the team current information regarding particular patients condition c. Adheres to policies. Performs daily check of patients records / condition f. Verifies the competency of the staff prior to delegating tasks Maintains a safe environment a. Management Of Resources And Environment 1 2 3 4 5 Organizes work load to facilitate patient care a. Plans the performance of tasks or activities based on priorities c. Reports necessary elements at the bedside to improve patient stay at hospital d. Determines the resources needed to deliver patient care b.IX. QUALITY IMPROVEMENT 1 2 3 4 5 Gathers data for quality improvement a. 2. 4. Demonstrate knowledge of method appropriate for the clinical problems identified b. procedures and protocols on prevention and control of infection c. Detects variation in the vital signs of the patient from day to day c. Encourage the patient to speak about what is relevant to his condition d. Checks proper functioning of equipment b. Determines tasks and procedures that can be safely assigned to other member of the team. Solicits feedback from patient & significant others regarding care rendered 2. Controls the use of supplies and equipment Ensures functioning of resources a. X. Finishes work assignment on time Utilizes resources to support patient care a. 5. Completes patients records g. b. earthquake and other emergency situations. Contributes relevant information about patient condition as well as unit condition and patient current reactions b. Identifies tasks or activities that need to be accomplished b. 1. Defines steps to follow in case of fire. Participates in nursing audits and rounds a.

Able to identify researchable problems regarding patient care and community health b. Reports actual and potential variance to patient care d. Able to talk about the results of findings to colleagues / patients / family and to others b. Recommends solutions to identified problems a. = TOTAL COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ . recommends practical solutions appropriate for the problem 3. Submits research findings to own agencies and others as appropriate 4. Documents observed variance regarding patient care and submits to appropriate group within 24 hours b. Disseminates results of research findings a. Identifies actual and potential variance to patient care c. Gives appropriate suggestions on corrective and preventive measures b. Recommends actions for implementation a. Endeavours to publish research c. Based on the analysis of data gathered. Gather data using different methodologies a. TOTAL = COMMENT:___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ XI. Makes use of evidence-based nursing to ameliorate nursing practice. Applies research findings in nursing practice a.3. Combines quantitative and qualitative nursing design thru simple explanation on the phenomena observed d. Analyzes data gathered 2. Gives an objective and accurate report on what was observed rather than an interpretation of the event. Identifies and reports variances a. Identify appropriate methods of research for a particular patient / community problem c. c. Utilizes findings in research in the provision of nursing care to individuals / groups / communities b. RESEARCH 1 2 3 4 5 1. Communicates and discusses with appropriate groups. Submits reports to appropriate groups within 24 hours 4.

Quality Improvement 11. Record management 9. Collaboration and teamwork 4. Communication 3.SUMMARY POINTS EARNED  Patient Care Competencies 1. Research ________ ________ ________ ________ ________ ________ ________ ________ ________ _________ _________ GRANDTOTAL TOTAL FINAL RATING: __________________________ RATER’S SIGNATURE: __________________________ DATE: ____________________ CONFORME: __________________________ RATEE __________________________ CHIEF NURSE DATE: ____________________ CONCUR: DATE: ____________________ . Safe and quality nursing care 2. Health Education  Empowering 5. Legal responsibility 6. Personal and professional development  Enhancing 8. Ethico-moral responsibility 7. Management of resources and environment  Enabling 10.

RM. 2011 . NONESCOST Graduate School SY 2011-2012 Student August 14. LUISA S.D. Field Experience in Nursing Administration & Management Professor PREPARED BY LISETTE GRACE B.N. UMADHAY. MAN.STAFF NURSE PERFORMANCE EVALUATION SHEET “11 KEY AREAS OF RESPONSIBILITIES” SUBMITTED TO MA. PARREÑAS. Ed. RN. R.

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