PERFORMANCE RATING SCALE

OPERATING ROOM

DESIGNATION: SCRUB NURSE

NAME:
SECTION:
DATE OF
EXPOSURE:
AREA OF
EXPOSURE:
TOTAL
GRADE:

Instruction: Indicate your rating to the item by checking appropriate cell for each task.

A. SAFE AND QUALITY NURSING CARE (30%) 30

5 Demonstrates mastery of skills in performing nursing actions or procedures at all times without supervision.
4 Demonstrates mastery of skills in performing nursing actions or procedures with minimal supervision most of the time.
3 Adequate acceptable competence with occasional supervision.
2 Inadequate skills in performing nursing actions or procedures needing constant supervision.
1 Incompetent in performing nursing actions or procedures even with supervision.
I. Utilizes the nursing process in the care of OR client. 5 4 3 2 1 COMMENTS
a. Obtain comprehensive client’s information by checking complete accomplishment of
1 5
the preoperative checklist/client’s chart.

1 b. Identifies priority needs of the client in the Operating Room. 5

1 c. Provides needed nursing interventions based on the identified needs. 5
1 d. Monitors client’s responses to surgery. 5

II. Promotes safety and comfort of clients inside the OR.

a. Transports and transfer client from the stretcher to OR bed. OR bed to stretcher,
1 stretcher to RR bed. (e.g. use of side rails)
5

1 b. Places properly grounding pad under the patient for electro-surgical equipment. 5
1 c. Monitor vital signs. 5
1 d. Provides physical comfort utilizing comfort devices/ technique. 5
1 e. Assist in proper and safe positioning of clients in preparation for surgery. 5
1 f. Observes universal precautions in handling body fluids. 5
III. Performs the function of the scrub nurse.
1 a. Drapes the operative field correctly. 5
1 b. Performs surgical scrub correctly. 5
1 c. Dons surgical gowns and gloves correctly. 5
1 d. Serves gowns, gloves and drapes aseptically. 5
1 e. Prepares surgical instruments in functional arrangement. 5
f. Hands instruments, sponges, sutures and other needed materials according to the
1 5
surgeon’s preference.
1 g. Performs surgical count accurately. 5
1 h. Performs after care of the instruments. 5

IV. Performs the function of the circulating nurse.

1 a. Prepares the surgical table and all needed equipment and supplies for surgery. 5
1 b. Assist the anesthesiologist in the induction of anesthesia. 5
1 c. Performs the surgical skin preparation of the client. 5
d. Checks with the scrub nurse the completeness of the surgical sponges, needles and
1 5
instruments.
1 e. Anticipates the needs of the surgical team. 5
1 f. Ensures intactness and functionality of all contraptions. 5
1 g. Helps in the aftercare of equipment and the OR as a whole. 5
1 h. 2Hands additional instruments and supplies as needed aseptically. 5
1 i. Checks the integrity and sterility of the OR packs. 5
1 j. Sets up the OR room and needed equipment. 5
1 k. Receives the client for surgery/endorses client post operatively. 5
1 l. Executes legal orders of the surgeon/anesthesiologists accurately and timely. 5
1 m. Administer medication and other health therapeutic safely. 5
1 n. Monitor client’s progress during surgery and immediate post-op phase. 5
 TOTAL 160 160 0 0 0 0
SCORE 160
TRANSMUTED 100
B. MANAGEMENT OF RESOURCES AND ENVIRONEMENT (10%) 7.8
5 Demonstrates mastery of skills in performing nursing actions or procedures at all times without supervision.
4 Demonstrates mastery of skills in performing nursing actions or procedures with minimal supervision most of the time.
3 Adequate acceptable competence with occasional supervision.
2 Inadequate skills in performing nursing actions or procedures needing constant supervision.
1 Incompetent in performing nursing actions or procedures even with supervision.
5 4 3 2 1 COMMENTS
1 a. Organize workload to facilitate timely patient care. 5
1 b. Ensures availability, completeness, and functionality of OR equipment. 4
c. Observes protocol in unrestricted, semi-restricted, and restricted areas in
1 3
the OR
1 d. Performs proper disposal of hazardous and non-hazardous wastes. 2
1 e. Utilizes adequate and appropriate resources to support OR team. 3
1 f. Observes OR policies, procedures and protocols on infection control. 4
1 g. Maintain a safe environment in the OR by observing principles of aseptic
4
1 technique.
h. Awareness of the institutional evacuation and location plan both for fire,
1 4
earthquake and other major emergencies.
TOTAL 45 5 16 6 2 0
SCORE 29
TRANSMUTED 78
C. HEALTH EDUCATION (10%) 9.4
5 Demonstrates mastery of skills in performing nursing actions or procedures at all times without supervision.
4 Demonstrates mastery of skills in performing nursing actions or procedures with minimal supervision most of the time.
3 Adequate acceptable competence with occasional supervision.
2 Inadequate skills in performing nursing actions or procedures needing constant supervision.
1 Incompetent in performing nursing actions or procedures even with supervision.
5 4 3 2 1 COMMENTS
a. Implements appropriate health education activities to client based on
1 4
assessment of the intra-operative client
1 b. Reinforces preoperative health teachings of client. 5
TOTAL 10 5 4 0 0 0
SCORE 9
TRANSMUTED 94
D. LEGAL RESPONSIBILITY (5%) 3.75
5 Demonstrates mastery of skills in performing nursing actions or procedures at all times without supervision.
4 Demonstrates mastery of skills in performing nursing actions or procedures with minimal supervision most of the time.
3 Adequate acceptable competence with occasional supervision.
2 Inadequate skills in performing nursing actions or procedures needing constant supervision.
1 Incompetent in performing nursing actions or procedures even with supervision.
5 4 3 2 1 COMMENTS
a. Adheres to legal and institutional protocols regarding informed consent and
1 3
other legal documents.
TOTAL 5 0 0 3 0 0
SCORE 3
TRANSMUTED 75
E. ETHICO-MORAL RESPONSIBILITY (10%) 9.4
5 Demonstrates mastery of skills in performing nursing actions or procedures at all times without supervision.
4 Demonstrates mastery of skills in performing nursing actions or procedures with minimal supervision most of the time.
3 Adequate acceptable competence with occasional supervision.
2 Inadequate skills in performing nursing actions or procedures needing constant supervision.
1 Incompetent in performing nursing actions or procedures even with supervision.
5 4 3 2 1 COMMENTS
1 A. Respects the right of the OR client 5
B. Accept responsibility and accountability for own decisions and actions as an
1 OR nurse. 4

1 C. Maintains privacy and confidentiality of client’s information. 4

1 D Adheres to the Code of Ethics for Nurses. 5
TOTAL 20 10 8 0 0 0
SCORE 18
TRANSMUTED 94
 F. PERSONAL AND PROFESSIONAL GROWTH (5%) 3
5 Demonstrates mastery of skills in performing nursing actions or procedures at all times without supervision.
4 Demonstrates mastery of skills in performing nursing actions or procedures with minimal supervision most of the time.
3 Adequate acceptable competence with occasional supervision.
2 Inadequate skills in performing nursing actions or procedures needing constant supervision.
1 Incompetent in performing nursing actions or procedures even with supervision.
5 4 3 2 1 COMMENTS
1 a. Performs OR functions according to professional standards.
b. Possesses positive attitude towards learning surgical and OR related
1
knowledge and skills.
TOTAL 10 0 0 0 0 0
SCORE 0
TRANSMUTED 60
G. QUALITY IMPROVEMENT (5%) 3
5 Demonstrates mastery of skills in performing nursing actions or procedures at all times without supervision.
4 Demonstrates mastery of skills in performing nursing actions or procedures with minimal supervision most of the time.
3 adequate acceptable competence with occasional supervision.
2 Inadequate skills in performing nursing actions or procedures needing constant supervision.
1 Incompetent in performing nursing actions or procedures even with supervision.
5 4 3 2 1 COMMENTS
a. Participates in quality improvement activities related to infection control and
1
success OR operation.
1 b. Identifies and reports variances in sterility and other OR activities.
TOTAL 10 0 0 0 0 0
SCORE 0
TRANSMUTED 60
H. RESEARCH (5%) 3
5 Demonstrates mastery of skills in performing nursing actions or procedures at all times without supervision.
4 Demonstrates mastery of skills in performing nursing actions or procedures with minimal supervision most of the time.
3 Adequate acceptable competence with occasional supervision.
2 Inadequate skills in performing nursing actions or procedures needing constant supervision.
1 Incompetent in performing nursing actions or procedures even with supervision.
5 4 3 2 1 COMMENTS
1 a. Ability to find new and relevant research OR related research studies.
b. Disseminates results of OR related research findings to clinic group and
1
other members of the OR teams appropriate.
TOTAL 10 0 0 0 0 0
SCORE 0
TRANSMUTED 60
I. RECORDS MANAGEMENT ( 10%) 6
5 Organizes systematically and accurately all data related to clients without supervision.
4 Organizes systematically and accurately all data related to clients with minimal supervision.
3 Adequate acceptable competence with occasional supervision.
2 Unable to systematically organize all data related to clients needing constant supervision.
1 Unable to systematically organize all data related to clients even with constant supervision.
5 4 3 2 1 COMMENTS
a. Maintain legible, accurate and updated documentation of patient care in the
1
chart and OR forms.
b. Submits timely, complete and accurate surgical slips and OR write-ups for
1
case handled.
TOTAL 10 0 0 0 0 0
SCORE 0
TRANSMUTED 60
 J. COMMUNICATION (5%) 3
5 (5) Displays appropriate communication skills with the client and significant others without supervision.
4 (4) Displays appropriate communication skills with the client and significant others with minimal supervision.
3 (1) Adequate acceptable competence with occasional supervision.
2 (2) Unable to display appropriate communication skills needing constant supervision.
1 (1) Unable to display appropriate communication skills even with supervision.
5 4 3 2 1 COMMENTS
a. Utilizes therapeutic communication skills with patient, significant others and
1
members of the health team.
1
b. Establishes professional relationships with members of the
surgical/health team.
1 c. Utilizes proper channel of communication.
1 d. Observe complete and accurate endorsement procedures.
e. Uses appropriate information mechanism to facilitate communication inside
1
the OR and with other departments in the hospital.
TOTAL 25 0 0 0 0 0
SCORE 0
TRANSMUTED 60
A. COLLABORATION AND TEAMWORK (5%) 3
5 Relates confidentially and shows professionalism with the health team and client without supervision.
4 Relates confidentially and shows professionalism with the health team and client with minimal supervision.
3 Adequate acceptable competence with occasional supervision.
2 Unable to r elate and show professionalism with the health team and client needing constant supervision.
1 Unable to r elate and show professionalism with the health team and client even with supervision.
5 4 3 2 1 COMMENTS
1 a. Collaborates plan of care with other members of the health team.
TOTAL 5 0 0 0 0 0
SCORE 0
TRANSMUTED 60

CLINICAL INSTRUCTOR STUDENT NAME

DATE DATE
GR %
SUMMARY A. SAFE & QUALITY NURSING CARE (30%) 100 30
B. MANAGEMENT OF RESOURCESAND ENVIRONMENT (10%) 78 7.8
C. HEALTH EDUCATION (10%) 94 7.8
D. LEGAL RESPONSIBILITY (5%) 75 3.8
E. ETHICO-MORAL RESPONSIBILITY (10%) 94 9.4
F. PERSONAL & PROFESSIONAL DEVELOPMENT(5%) 60 3
G. QUALITY IMPROVEMENT (5%) 60 3
H. RESEARCH (5%) 60 3
I. RECORDS MANAGEMENT (5%) 60 6
J. COMMUNICATION(5%) 60 3
K. COLLABORATION AND TEAM WORK (5%) 60 3