NEW ERA UNIVERSITY

College of Nursing
PERFORMANCE EVALUATION TOOL
ONE-ON-ONE IV INSERTION
Name:___________________________ Group No _____ Date: _________Grade:_________
DIRECTION: Rate the students performance utilizing the scale below:
5 Demonstrate procedure properly, explains the correct rationale behind action
4 Demonstrates procedure properly, correct rationale was not thoroughly explained.
3 Demonstrate procedure properly, no/ wrong rationale stated.
2 Procedure not completely and accurately done, correct rationale was not thoroughly explained
1 Procedure not properly done, no/ wrong rationale stated
0 Procedure not done
COMPETENCIES
A. ATTITUDE (10%)
1. Reports on time.
2. Wears complete prescribed uniform.
3. Neat and well groomed.
4. Has complete articles needed for the activity.
5. Observe proper decorum.
6. Acknowledges criticism/suggestions cheerfully.
7. Shows interest in the activity.
B. KNOWLEDGE (20%)
1. States objectives of this activity.
2. Uses appropriate term.
3. States steps of the procedure in correct order.
4. Explains rationale of every step.
C. SKILLS (70%)
1. Do hand hygiene before and after procedure.
2. Follow procedure in IV insertion aseptically and
accordingly.
3. Discard Waste Materials according to Health Care Waste
Management (DOH/DENR).
Suggested Score
___ 1st attempt
___ 2nd attempt
___ 2nd attempt with
Hematoma
___ 3rd attempt
___ 3rd attempt with
Hematoma

5 4 3 2 1 0

Remarks

Score
20 points highest score
15 points only
less 2-3 points
10 points only
less 2-3 points

EVALUATED BY:
_______________________
Clinical Instructor

Fundamentals of Nursing Checklist

___________________________
Students Signature

Skills Laboratory