STUDENT CLINICAL EVALUATION FORM

Name of Student Nurse:____________________________________ Year & Section: _____________

Week: Week: Week: Week:

Criteria Date: Date: Date: Date:
5 – Excellent, 4 – Good, 3 – Fair, 2 – Poor, 1 – Very Poor Area: Area: Area: Area:
I. Attendance and Participation
a. Reports to the agreed area on time.
b. Secures complete supplies needed in the area.
c. Performs assigned nursing tasks effectively, efficiently
and safely.
d. Maintains a harmonious relationship with the patient,
family, peers, teacher and the health care team.
e. Presents oneself in a tidy and complete clinical uniform.
Total
II. Clinical Competency
a. Assesses the patient / the family utilizing various
appropriate assessment tools, methods and techniques.
b. Renders a safe and quality nursing care to the patient /
family.
c. Performs effective and efficient nursing interventions
guided by the nursing ethico-legal principles, standards
and the CDU-CN Values
d. Collaborates with the health care team in promoting
patient health, recovery, rehabilitation.
e. Documents relevant and accurate records and reports
as reflected on the monitoring sheets, focus charting and
etc.
Total
Evaluated by:
Name and Signature of Staff Nurse (use Trodat)

1
III. Ward Activities
a. Presents a health education that provides excellent opportunity to learn new skills and gain
knowledge about nursing care management
b. Develops a comprehensive nursing care plan through the ward activity and evaluate
its effectiveness

c. Performs an efficient implementation of the ward activity with the use of resource materials

d. Produces a patient-centered learning activity considering the different domains of learning.

Evaluated by:
Name and Signature of Clinical Teacher (use Trodat)

Remark:
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Record Adviser:

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