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University of Perpetual Help System-Las Pinas Campus LAS PINAS CITY COLLEGE OF NURSING

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST Concept: Acute Biological Crisis Area: EMERGENCY ROOM

Name: ________________________ Year___ Section___ Group Number___

Date: ________________ Rating: _______________

Direction:

Put a check on the skills observed / performed, of not please include remarks on the space provided.

Legend:

321-

Is at a very satisfactory level. Has thorough knowledge and understanding of the said case/topic. Could do and plan intervention on his/her own. At satisfactory level. Has enough understanding to handle the case but needs Careful guidance. Needs to be reevaluated. Competency is at an unsatisfactory level and needs to be reoriented on the subject/case at hand.

A. ASSESSMENT 10% 1. Assess different manifestations that are related to Acute Biological Crisis through the different methods used in physical and appropriate data gathering. 2. Performs physical examinations correctly and with confidence.

Wt 2

3

2

1

Score

Remarks

2

3. Identifies and differentiates between normal and 2 abnormal findings in Acute Biological Cases. 2 4. Determines the significance of laboratory and diagnostic findings to the emergent problems 2 5. Picks out critical and essential data in nursing history relevant to the current situations.
Subtotal 10

A. PLANNING 4% 1. Knowledge in setting goals and prioritization of patients needs with Acute Biologic Crisis in the emergency room. 2. Identify changes in patient’s needs and nursing problems as they occur and make necessary adjustments in nursing measures.
Subtotal

Wt 2

3

2

1

Score

Remarks

2

4

A. INTERVENTIONS 15% 1. Assess the capability needed by the client for self-management in the emergency. 2. Ensures safety, comfort and privacy in rendering care of patients with acute biologic crisis. 3. Provides necessary curative measures. 4. Provides immediate restorative/rehabilitative measures during temporary stay in the ER. 5. Utilizes available physical and professional resources. 6. Makes referrals to appropriate health professionals, as needed. 7. Shows commitment to the welfare of the client. 8. Implements the plan of care jointly with the client. 9. Performs nursing procedures/activities: 9.1 with ease and confidence 9.2 correctly 9.3 systematically 9.4 practices bioethical principles in care

Wt 1 2

3

2

1

Score

Remarks

1 1

1 1 1 1 1 1 1 1

9.5 provides after care 9.6 demonstrate situational flexibility and adaptability
Subtotal

1 1 15

A. EVALUATION 4% 1. Evaluates plan of care of client using the outcome criteria and performs appropriate documentation and recording of changes in the client’s evident status after the interventions.
2. Displays critical thinking in the analysis of the current management being employed and modifications that has to be done as needed. 3. Discusses with the appropriate health team results of interventions. 4. Accepts suggestions, constructive criticisms and employ appropriate modifications in the plan of care. Subtotal Grand Total

Wt 1

3

2

1

Score

Remarks

1 1 1 4 100

________________________

_________________________

Student’s Signature

Clinical Instructor’ Signature

University of Perpetual Help System-Las Pinas Campus LAS PINAS CITY

COLLEGE OF NURSING
CLINICAL PERFORMANCE AND EVALUATION CHECKLIST Area: OPERATING ROOM

Name: ____________________________ Year___ Section___ Group Number___

Date: _________________ Rating: _______________

Direction:

Put a check on the skills observed / performed, of not please include remarks on the space provided.

Legend:

321-

Is at a very satisfactory level. Has thorough knowledge and understanding of the said case/topic. Could do and plan intervention on his/her own. At satisfactory level. Has enough understanding to handle the case but needs Careful guidance. Needs to be reevaluated. Competency is at an unsatisfactory level and needs to be reoriented on the subject/case at hand.

A. ASSESSMENT 10% 1. Obtains and analyzes pertinent data concerning patient’s condition. 2. Determines and categorizes clinical assessment of the patient. 3. Interprets prudently the physician’s order. 4. Checks and accomplishes pre-operative checklist prior to surgical procedure.

Wt 2 2 2 2

3

2

1

Score

Remarks

5. Assess patient’s physiological, psychological and patient’s emotional status.
Subtotal

2 10

A. PLANNING 4% 1. Formulates appropriate nursing diagnosis based from thorough patients assessment. 2. Rationalizes principles of aseptic technique. 3. Checks functionality of the operating room / delivery room equipment such as suction machine, cautery and OR lights. 4. Prepares and selects surgical supplies concerning the patient’s surgical procedure.
Subtotal

Wt 1 1 1

3

2

1

Score

Remarks

1 4

A. INTERVENTION 15% Pre – Operative Phase 1. Identifies patient and verifies procedure to be done. 2. Secures consent. 3. Checks for clearances (cardio-pulmonary clearance, pedia clearance), diagnostic procedures.
Intra – Operative Phase 1. Explains proper position for induction of anesthesia and operation to be performed. 2. Demonstrate proper aseptic/antiseptic technique, sterile drapings and handling of instruments. 3. Maintains sterility of the operating room and sterile field. Post – Operative Phase

Wt

3

2

1

Score

Remarks

1 1 1

2 2

2

1. Monitors vital signs immediately after the operation. 2. Evaluates patient’s recovery from anesthesia. 3. Discusses the emergency resuscitative devices, equipment and emergency drugs in the recovery room. Subtotal

2 2 2

15

A. EVALUATION 4% 1. Evaluates plan care after applying necessary nursing interventions. 2. Discusses appropriate health teaching (sterile wound care) 3. Performs proper documentation and other important details are needed. 4. Participates in activity during postconference.
Subtotal Grand Total

Wt 1 1 1 1 4 100

3

2

1

Score

Remarks

________________________

_________________________

Student’s Signature

Clinical Instructor’ Signature

University of Perpetual Help System-Las Pinas Campus LAS PINAS CITY COLLEGE OF NURSING
CLINICAL PERFORMANCE AND EVALUATION CHECKLIST Concert: Staff Nursing Area: GENERAL WARD

Name: ____________________________ Year___ Section___ Group Number___

Date: _________________ Rating: _______________

Direction:

Put a check on the skills observed / performed, of not please include remarks on the space provided.

Legend:

321-

Is at a very satisfactory level. Has thorough knowledge and understanding of the said case/topic. Could do and plan intervention on his/her own. At satisfactory level. Has enough understanding to handle the case but needs Careful guidance. Needs to be reevaluated. Competency is at an unsatisfactory level and needs to be reoriented on the subject/case at hand.

A. KNOWLEDGE 1. Knowledge in gathering data 2. Knowledge of the different methods used in physical assessment. 3. Adequate knowledge regarding normal values and other laboratory results. 4. Identifies nursing problems of patient and its cause. 5. Explains scientific principles behind patient’s condition and management. 6. Knowledge in setting goals and prioritization of patient’s needs. 7. Knows intervention to be given and the rationale.

3

2

1

REMARKS

8. Knows the theories and rationale behind nursing procedures being implemented. 9. Knows the principle of drug administration and its action. 10. Knowledge on how to relate nursing interventions to outcomes. Subtotal:

B. SKILLS 1. Checks, records and interprets accurately the vital signs of assigned patients. 2. Ability to manipulate and care for the equipment. 3. Ability to collect specimens for the laboratory examination. 4. Demonstrate skill in providing comprehensive nursing care. 5. Performs nursing procedures with maximum result with minimum time, effort and materials at her/his level. 6. Implements nursing care according to priorities. 7. Provides health teaching for patient and his family as manifested by good communication skill. 8. Coordinates with other members of the health team with regards to patient’s condition. 9. Ability to transcribe doctor’s order. 10. Records accurately patient’s conditions and nursing intervention. Subtotal:

3

2

1

Remarks

C. ATTITUDES AND VALUES

3

2

1

Remarks

1. Punctuality and regular in attendance. 2. Professionalism in uniform. 3. Honesty and sincerity. 4. Resourcefulness and creativity. 5. Sense of responsibility. 6. Initiative, Diligence and Industry. 7. Tolerance and Patience. 8. Polite and Respectful to self and others. 9. Works harmoniously with others. 10. Aware and understands the needs and emotions of others. Subtotal:

_____________________

________________________

Student’s Signature

Clinical Instructor’ Signature

University of Perpetual Help System-Las Pinas Campus LAS PINAS CITY
College of Nursing

Name: ____________________________________Date:___________________ Yr/Sec: ______________Group:___________ rating: __________________

Area: ____________________Clinical Instructor: __________________________

P E R F O R M A N C E

E V A L U A T I O N

T O O L

(STUDENT HEAD NURSE TO STUDENT NURSE)

NUMERICAL RATING 5 4 3 2 1

QUANTITATIVE Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

DESCRIPTION Carries out expected tasks in a very consistent manner with minimal guidance and supervision Carries out expected tasks in a consistent manner with minimal guidance and supervision Carries out expected tasks in a moderately consistent manner with frequent guidance and supervision Carries out expected tasks in a rarely consistent manner with close guidance and supervision Does not carry out expected tasks even with close guidance and supervision

PERFORMANCE I. ASSESSMENT / PLANNING 1.1 Establishes rapport with subordinates

RATING

1.2 Able to involve patients in plan of care 1.3 Punctual and prompt in all activities 1.4 Able to maintain stability under pressure 1.5 Gathers data using interview, observation, records review and reports 1.6 Formulates appropriate nursing care plan 1.7 Wears complete prescribed RLE uniform II. IMPLEMENTATION a. Carries out assigned tasks based on the criteria of distribution of assignments b. Follows principles of time management c. Equipped with required paraphernalia for RLE d. Observes proper channels of communication e. Carries out plan of care, including: A. Bedside Care B. Administration of medications C. Administration of treatments (nebulization, IVF) f. Shows initiative in performing tasks g. Accomplishes delegated tasks within prescribed time frame h. Provides psychological and spiritual support to patients i. Accepts supervision and criticisms j. Conducts appropriate health teachings III. EVALUATION 1. Notifies immediate superior about untoward situations or conditions related to patient care in the area 2. Make revisions in the plan of care as necessary 3. Evaluates Nursing Care rendered V. ETHICOLEGAL CONSIDERATIONS 1. Demonstrates honesty at all times

2. Conducts self in a tactful manner 3. Keeps confidential patient information 4. Observes the PNA Code of Ethics 5. Guided by RA 9173 6. Observes the 11 Core Competency Guidelines

REMARKS

:

ACTUAL SCORE x 100

EVALUATED BY :

STUDENT HEAD NURSE

TOTAL SCORE

CONFORME BY :
STUDENT STAFF NURSE

NOTED BY:
CLINICAL INSTRUCTOR

University of Perpetual Help System-Las Pinas Campus LAS PINAS CITY
College of Nursing

HEAD NURSE PERFORMANCE CHECKLIST Name: ____________________________________Date:___________________ Yr/Sec: ______________Group:___________ rating: __________________ Area: ____________________ Clinical Instructor: __________________________

A. Knowledge 1. Applies as appropriate theory as a basis for decision making in nursing practice. 2. Assesses staffs presenting symptoms to determine a nursing diagnosis and plan of action based on a medical expertise and knowledge. 3. Knowledge in communication, clarification and interpretation of existing problems with staff and nursing responsibilities. 4. Inform the staff of the likely causes of errors defects and waste. 5. Suggest in which risk, errors, quality of problems maybe reduce. A. Attitude 1. Neat and well groomed. Adheres to dress code. 2. Punctual in reporting for duty 3. Complies with the code of ethics of the nursing profession and upholds and implements school rules. 4. Assist in training staff in particular by setting a good example. 5. Promotion of professional responsibility, accountability and behavior. A. Skills 1. Provide leadership in the assessment, planning, implementation, and evaluation of comprehensive school health program. 2. Respond to the student/ staff medical emergencies. 3. Instruct subordinates in appropriate method and procedure in providing care. 4. Initiate and facilitate any steps necessary to improve methods, equipments, materials and condition in the

5

4

3

2

1

work area for which they are responsible.
Equivalent: ______________ Rating: _______________

Point scale 5 4

Grade 85 82-84 Excellent Very Satisfactory Satisfactory Fair

Equivalent Carries out expected behavior in a very consistent and independent manner with less supervision and guidance. Carries out expected behavior in a consistent and independent manner that requires minimal supervision and guidance. Carries out expected behavior in rarely independent manner requiring more supervision and guidance. Carries out expected behavior in rarely independent manner requiring close supervision and guidance.

3 2 1

79-81 75-78 74 and below

Needs Carries out expected behavior under close supervision and improvement guidance.

Name: _____________________ Yr/sec./Group#:______________

Area: ___________________________ Clinical Instructor: _________________

Scaling Interpretation

This evaluation is to determine and appraise the performance of the staff according to their assign task. By writing the appropriate score in the proper column denoting the extent to which the nurses performed these functions.

Criteria for Grading 15% Decorum Attendance------------------------------------------20% Requirements----------------------------------------------------25% Quiz----------------------------------------------------------------40% performance------------------------------------------------------

_____________ Total 100%

Prepared By: ROMMEL JOHN A. ALAVAZO BSNIV-(IV) Group 3A

PERFORMANCE CHECKLIST KNOWLEDGE 1. Gathers data appropriately and completely, then validating it focusing function needing assistance support 2. Analyze and interpret collected data 3. Knows the correct way of doing physical assessment. 4. Gives attention and synthesize the significant laboratory findings 5. Knowledge in identifying nursing problems and categorizing it according to the patients need. 6. Knows the rationale behind every intervention given for the care of the patient. 7. Have knowledge in giving proper instruction for medicine a. classification b. nursing responsibility c. drugs and solution 1. Explain or discuss the report clearly and able to answer question correctly. 2. Knowledge in preparation of patient for any diagnostic procedure 3. Knows how to formulate an accurate nursing care plan for particular cases. 5 4 3 2 1

SKILLS 1. Ability to give and respond to the care needed by the patient 2. Perform procedure properly such as doing physical assessment, taking VS, and giving medication as ordered.

5

4

3

2

1

3. Able to provide or assist patient in performance of activities of daily living whenever needed. 4. Always guided in precautionary and preventive measure in providing care to the patient. 5. Able to give health teachings clearly to the patient. 6. Communicate effectively in identifying the needs of the patient. 7. Properly handling an instance of emergency situation. 8. Implement Nursing care plan appropriately 9. Reassesses patient to determine whether a remodification of care plan is necessary. 10. Able to conduct discharged planning with the patient, his family and significant others.

Legend: 5 – Outstanding (85) 4 – Very Satisfactory (83-84) 3 - Moderately satisfactory (81-82) 2 – Minimally satisfactory (75-80) 1 – Unsatisfactory (74 and below)