Evaluation Tool (Competency Based) - Nonescost

Republic of the Philippines
PNO-NONESCOST College of Nursing

Cadiz City, Negros Occidental
NAME OF S!"EN ############################# C$%N%CA$ AREA #######################
%NC$!S%&E "AE OF R$E E'PER%ENCE ############### (RA"E ###############################
CLINICAL PERFORMANCE RATING SCALE: HOSPITAL BASED ER! OPD "n# $ARD%
LE&EL I&%
Dire'(ion: Place the actual score if the beha)ior*s+ill described ,as de-onstrated. %f it ,as not
de-onstrated include re-ar+s in the space pro)ided.
Be)"*ior+S,ill S'ore Re-"r,s
D A
%. SAFE AND ./ALIT0 N/RSING CARE S.C%
A11lies ()e nursing 1ro'ess in ()e '"re of 1"(ien(s 2i() 1ro3le-s of
nu(ri(ion "n# -e("3olis-! 1er'e1(ion "n# 'oor#in"(ion! "l(er"(ions in
i--une res1onse "n# infe'(ion! 'ellul"r "3err"(ion "n#
re)"3ili("(ion4
/./ Assess the client0s health status based on1
Nursing 2istory
Measures )ital signs accurately
Physical Assess-ent
"iagnostic*$aboratory e3a-s
/ .4 Analyzes client0s data utilizing the appropriate theoretical
fra-e,or+.
/.5 "efines the nursing diagnosis
/.6 Prioritizes the nursing diagnosis
/.7 For-ulates plan of care.
%dentifies (oals*Ob8ecti)es
Specifies appropriate nursing inter)entions
"efines e)aluation criteria
/.9 %-ple-ents appropriate inter)entions
2ealth pro-oting inter)entions
%llness pre)enting inter)entions
Curati)e*restorati)e inter)entions
Supporti)e biobeha)ioral inter)entions
Rehabilitati)e inter)entions
%nter)entions specific to the nursing diagnosis identified
Obser)es principles for safety, pri)acy and co-fort ,hen pro)iding
care.
(i)es full attention to patient*client ,hen gi)ing care.
Pro)ides nursing care based on the indi)idual0s needs
5
4
5
4
4
5
4
5
5
4
4
4
5
5
4
4
4
6
5
4
5
4
II4MANAGEMENT OF RESO/RCES! EN&IRONMENT AND
E./IPMENT MRE%
Adapts en)iron-ent to -a+e it conduci)e for healing*pleasing of the
patient.
4
III4 HEALTH ED/CATION HE%
Pro)ides appropriate health education and health teachings 4
I&4 LEGAL RESPONSIBILITIES LR%
Maintains confidentiality of patient*client and staff.
Safeguards the indi)idual0s rights to pri)acy
Pre)ents and*or -anages proble-s related ,ith specific phase of
the nurse : client relationship.
4
/
/
&4 PERSONAL AND PROFESSIONAL DE&ELOPMENT PPD%
De-ons(r"(es 1osi(i*e "((i(u#es 35:
7./ Obser)es bedside -anners and courtesies.
7.4 Respects client0s spirituality and cultural needs.
/
/
7.5 "e-onstrates honesty in reporting*recording data.
7.6 "e-onstrates co-passion, genuine concern for patient0s ,elfare,
and caring not only for patient but also to the fa-ily*support syste-.
7.7 Presents self in a -anner that pro-otes the i-age of nursing.
;ell groo-ed
Pleasant disposition
4

4
/
/
&I4 ./ALIT0 IMPRO&EMENT .I%
E)aluates client0s response*outco-es of care based on criteria
!ses feedbac+*clinical super)ision to i-pro)e nursing care.
Sho,s ho, feelings*reactions can be -anaged to -aintain
standards of care.
!ses an updated re)ie, of literature in1
< "e)eloping the nursing care plan.
< ;ard conference*Case presentation
5
4
4
4
&II4 ETHICO-MORAL RESPONSIBILITIES EMR%
Dis1l"5s self #ire'(ion "n# self #is'i1line
Reports for duty on ti-e.
Sub-its re=uire-ents on ti-e.
Finishes ,or+ on ti-e.
Sho,s initiati)e in acti)ities.
"e-onstrates effecti)e ti-e -anage-ent
"e-onstrates honesty in reporting*recording data.
/
/
/
4
4
4
&III4 RESEARCH
Proposes possible solutions*options to proble-s*issues identified
utilizing research studies
4
I64 RECORD MANAGEMENT RM%
"e-onstrates accuracy and honesty in recording and reporting4 4
64 COMM/NICATION
"e-onstrates therapeutic co--unication s+ills.
%ntroduces self and addresses patients*clients, other indi)iduals as
they prefer to be addressed.
reats others ,ith respect regardless of bac+ground.
4
/
/
6I4 COLLABORATION AND TEAM$OR7
S)o2s le"#ers)i1 in '"ring for ()e 1"(ien(s 35:
Collaborates ,ith -e-bers of the health tea- in)ol)ed in client
care
%nitiates acti)ities or inter)entions to pro-ote*-aintain health of
pre)ent illness.
Supports the rights of other pro)iders to suggest alternati)es to
the plan of care.
4
4
/
TOTAL SCORE />>
GRADE E./I&ALENT
Co--ents1 ########################################################
Signature of Student1 ######################
Signature of eacher1 #####################
"ate of E)aluation1 #######################
CLINICAL PERFORMANCE E&AL/ATION GRADING S0STEM:
89 :;; < :4;; =; => < ?4>;
8? 8> < :4?> 9> 98 < ?4=>
@@ 8: < :4>; 9; 9A < B
@A @= < :4=> >> >8 < A
@; @B < ?4;; BELO$ >> < >
=9 =8 < ?4?>
CLINICAL PERFORMANCE RATING SCALE: HOSPITAL BASED OPD "n# $ARD%
LE&EL III%
D A
I4 SAFE AND ./ALIT0 N/RSING CARE S.C%
re)"3ili("(ion4
Nursing 2istory
Physical Assess-ent
fra-e,or+.
care.
5
4
5
4
4
5
4
5
5
4
4
4
5
5
4
4
4
6
5
4
5
6
II4 HEALTH ED/CATION HE%
III4 LEGAL RESPONSIBILITIES LR%
4
/
/
I&4 PERSONAL AND PROFESSIONAL DE&ELOPMENT PPD%
/
/
4
;ell groo-ed

4
/
/
&4 ./ALIT0 IMPRO&EMENT .I%
!sing feedbac+*clinical super)ision to i-pro)e nursing care.
standards of care.
5
4
4
4
&I4 ETHICO-MORAL RESPONSIBILITIES EMR%
/
/
/
4
4
4
&II4 RESEARCH
4
&III4 RECORD MANAGEMENT RM%
I64 COMM/NICATION
4
/
/
64 COLLABORATION AND TEAM$OR7
care
pre)ent illness.
the plan of care.
4
4
/
TOTAL SCORE />>
GRADE E./I&ALENT
Co--ents1 ########################################################
"ate of E)aluation1 #######################
89 :;; < :4;; =; => < ?4>;
8? 8> < :4?> 9> 98 < ?4=>
@@ 8: < :4>; 9; 9A < B
@A @= < :4=> >> >8 < A
@; @B < ?4;; BELO$ >> < >
=9 =8 < ?4?>
CLINICAL PERFORMANCE RATING SCALE: HOSPITAL BASED $ARD%
LE&EL II%
D A
re)"3ili("(ion4
Nursing 2istory
Physical Assess-ent
fra-e,or+.
care.
5
4
5
4
4
5
4
5
5
4
4
4
5
5
4
4
4
6
5
4
5
6
II4 HEALTH ED/CATION HE%
III4 LEGAL RESPONSIBILITIES LR%
4
/
/
I&4 PERSONAL AND PROFESSIONAL DE&ELOPMENT PPD%
/
/
4

;ell groo-ed
4
/
/
&4 ./ALIT0 IMPRO&EMENT .I%
!sing feedbac+*clinical super)ision to i-pro)e nursing care.
standards of care.
5
4
4
4
&I4 ETHICO-MORAL RESPONSIBILITIES EMR%
5
5
/
4
4
4
&II4 COMM/NICATION
4
/
/
&III4 COLLABORATION AND TEAM$OR7
care
pre)ent illness.
the plan of care.
4
4
/
TOTAL SCORE />>
GRADE E./I&ALENT
Co--ents1 ########################################################
"ate of E)aluation1 #######################
89 :;; < :4;; =; => < ?4>;
8? 8> < :4?> 9> 98 < ?4=>
@@ 8: < :4>; 9; 9A < B
@A @= < :4=> >> >8 < A
@; @B < ?4;; BELO$ >> < >
=9 =8 < ?4?>

LE&EL III "n# LE&EL I&
S/MMAR0 PERFORMANCE E&AL/ATION ACHIE&ING
INTRA-OPERATI&E CARE COMPETENC0
In A''or#"n'e 2i() PRC Bo"r# of Nursing Me-or"n#u- No4 ;: Series of ?;;8
Signature o)er Printed Na-e of Student1 #####################################
INTRA-OPERATI&E CARE
COMPETENCIES
DESIRED
RATING
:
ST
RLE
?
ND
RLE
B
RD
RLE
A&ERAGE
RATING
/. !tilizes the nursing process in the care
of OR client.
Obtains co-prehensi)e client0s
infor-ation by chec+ing co-plete
acco-plish-ent of the
preoperati)e chec+list*client0s
chart.
6
%dentifies priority needs of the
client at the Operating Roo-.
6
Pro)ides needed nursing
inter)entions based on identified
needs.
6
Monitor client0s response to
surgery.
4
4. Pro-otes safety and co-fort of patient
inside the OR.
4
5. Perfor-s functions of the scrub nurse.
Perfor-s surgical scrub correctly. 6
;ears sterile go,ns and glo)es
aseptically.
4
Prepares surgical instru-ents,
sponges, sutures, and other
supplies in functional
arrange-ent.
4
2ands instru-ents, sponges,
sutures, and other needed
-aterials according to surgeon0s
preference.
4
Perfor-s surgical count
accurately.
4
6. Perfor-s the functions of the circulating
nurse.
Anticipates the needs of the
surgical tea-.
4
Sets up the OR roo- and needed
e=uip-ent.
4
Recei)es client for
surgery*endorses client post<
operati)ely.
4
Assists in s+in preparation and
draping of client.
4
7. Ad-inisters -edications and other
health therapeutics safely.
4
II4 MANAGEMENT OF RESO/RCES AND EN&IRONMENT MRE%
/. Organizes ,or+ load to facilitate ti-ely
patient care.
6
4. !tilizes ade=uate and appropriate
resources to support the OR ea-.
4
5. Ensures functionality of OR resources. 4
6. Maintains a safe en)iron-ent at the OR
by obser)ing the principles of asepsis.
4
/. %-ple-ents appropriate health education
acti)ities to client based on needs
assess-ent.
4
/. Adheres to legal and institutional
protocols regarding infor-ed consent.
4
&4 ETHICO-MORAL RESPONSIBILITIES EMR%
/. Respects the rights of the OR client. 4
4. Accepts responsibility and accountability
for o,n decisions and actions as an OR
nurse.
4
&I4 PERSONAL AND PROFESSIONAL DE&ELOPMENT PPD%
/. Perfor-s OR functions according to
professional standards.
6
4. Possesses positi)e attitude to,ards
learning surgical and OR<related
+no,ledge and s+ills.
4
&II4 ./ALIT0 IMPRO&EMENT .I%
/. Participates in =uality i-pro)e-ent
acti)ities related to infection control and
successful OR operations.
4
4. %dentifies and reports )ariances in
sterility and other OR acti)ities.
4
&III4 RESEARCH R%
/. "isse-inates results of OR<related
research findings to clinical group and
other -e-bers of the OR tea- as
appropriate.
4
/. Maintain accurate and updated
docu-entation of patient care.
4
64 COMM/NICATION Co--%
/. Establishes rapport ,ith patients,
significant others and -e-bers of the
health tea-.
/
4. !ses appropriate infor-ation
-echanis-s to facilitate co--unication
inside the OR and ,ith other depart-ents
in the hospital.
4
6I4 COLLABORATION AND TEAM$OR7 CTM%
/. Collaborates plan of care ,ith other
-e-bers of the health tea-.
4
TOTAL SCORE =>
;hen (raded R$E0s ;ere Perfor-ed ?Specify Acade-ic @ear and Se-esterA
First (raded R$E 1 A'"#e-i' 0e"r CCCCCCCC :
s(
Se-4 CCC ?
n#
Se-4 CCC Su--er CCCC
Clinical %nstructor 1 N"-e CCCCCCCCCCCCCCCCCCCCCCC Sign"(ure CCCCCCCCCCCCCCCCCC
Li'ense Nu-3er: CCCCCCCCCCCCC &"li#i(5: CCCCCCCCCCCCCCCCCCC
Second (raded R$E 1 A'"#e-i' 0e"r CCCCCCCC :
s(
Se-4 CCC ?
n#
hird (raded R$E 1 A'"#e-i' 0e"r CCCCCCCC :
s(
Se-4 CCC ?
n#
&erified rue and Correct1
?Signature o)er Printed Na-esA
####################################
Clinical Coordinator
$icense Nu-ber1 ################# &alidity "ate1 ###########
####################################
Acade-ic @ear (raduated
###############################
"EAN


INTRA-PARTAL CARE COMPETENC0
INTRA-PARTAL COMPETENCIES DESIRED
RATING
ACT/AL
RATING
/. Obtains obstetrical history including parity, gra)ida score,
$MP, E"C, AO(, BO; onset of true labor.
4. Chec+s )ital signs.
5. Conducts physical e3a-ination.
6. Perfor-s $eopold Maneu)er.
7. Chec+s Fetal 2eart Rate and Fundic 2eight.
9. Monitor progress of labor*uterine contractions as to1
Fre=uency
"uration
%ntensity
%nter)al
C. Obser)es for the ti-ely rupture of -e-brane.
D. Coaches -other on process of labor.
6
/
4
4
4
/
/
/
/
/
4
PERFORMS F/NCTIONS D/RING ACT/AL LABOR
/. ransports clients safely ,hile pro)iding pri)acy.
4. Places -other in lithoto-y position.
5. Perfor-s perineal care using sterile techni=ue correctly.
6. Perfor-s proper hand scrub.
7. ;ears go,n and glo)es according to hospital policy.
9. Perfor-s RitgenEs Maneu)er safely.
C. Coaches -other on breathing and pushing techni=ues.
D. "eli)ers baby and placenta carefully.
Chec+s and -anages cord recoil correctly.
Cla-ps and cut the cord correctly.
%dentify signs of placental separation.
Chec+s the characteristic*co-pleteness of the
placenta.
F. Assesses a-ount of blood loss ?Nor-al1 G7>> ccA.
/>. E-ploys inter)entions to achie)e and -aintain a ,ell
contracted uterus to pre)ent*control he-orrhage.
!terine -assage
Correct ad-inistration of o3ytocin
Cold co-press
//. Assesses presence and degree of laceration.
/4. Assist in episiorrhaphy.
/5. Chec+s size, consistency and location of uterus.
/6. Perfor-s perineal care and applies pad correctly.
/7. Pro)ides e-otional support to the -other throughout labor
and deli)ery.
/9. E)aluates patient0s condition and records pertinent data
accordingly.
/C. Prepares patient for transfer to reco)ery roo-*,ard.
/
/
/
/
/
4
/
/
/
/
/
4
/
/
/
/
/
/
/
/
4
4
5
5
5
II4 MANAGEMENT OF RESO/RCES! EN&IRONMENT AND E./IPMENT MRE%
/. Prepares roo-, instru-ents and e=uip-ent needed.
Sterile drape
Sterile instru-ents and e=uip-ent Hforceps, scissors,
bulb syringe, gauze, suture, needle holder, catheter
?optionalAI.
Jelly pad
"isinfectant
4. Perfor-s sterilization procedure.
5. Maintains ade=uacy of supplies as the deli)ery progresses.
6. Maintains orderliness of the sterile table.
7. Obser)es precautionary -easures related to use of electrical
e=uip-ent.
9. Ensures a =uite en)iron-ent.
C. !ses supplies diligently.
D. Perfor-s after care of the -aterials and e=uip-ents used.
F. Ensures proper disposal of hospital ,aste including blood
and other fluids.
/
/
/
/
/
/
/
/
/
/
/
/
/. eaches client on basic preparation during labor and deli)ery
?can be done in the labor room).
4. Coaches0 client on breathing*bearing do,n techni=ue.
5. "e-onstrates proper Klatch<onL breastfeeding techni=ue
?done post-partum periodA.
6. (i)es instruction to parents regarding infant care before
discharge ?done post-partum periodA.
7. Pro)ides discharge instructions as to feeding, bathing,
ad-inistration of ordered -edications, appoint-ent dates for
post natal and ,ell baby chec+<up ?done post-partum periodA.
9. Responds to =uestions of clients and relati)es regarding
e3pectations.
/
4
/
/
/
/
/. Secures infor-ed consent in all procedures related to labor
and deli)ery.
4. Reports accurately and honestly the gender, ti-e of deli)ery
of the baby and placenta.
5. Ensures proper identification of the -other and ne,born.
6. "ocu-ents all pertinent data correctly and co-pletely.
/
4
4
/
&4 ETHICO-MORAL RESPONSIBILITIES EMR%
/. Respects the religious, cultural, and ethnic practices of the
fa-ily of the ,o-an in labor and deli)ery.
4. Pro-otes e-otional security by supporting needs.
5. Ensures pri)acy and confidentiality.
/
/
/
/. !pdates oneself ,ith the latest trends and de)elop-ent in
labor and deli)ery.
4. Pro8ects a professional i-age of a deli)ery roo- nurse.
5. Accepts criticis-s and reco--endations.
6. Perfor-s functions according to standards.
/
/
/
/
&II4 ./ALIT0 IMPRO&EMENT .I% (preferably done during post conferences)
/. %dentifies de)iation of practice fro- the standards.
4. Participates in audit practices in the deli)ery roo-*lying in.
5. Reco--ends correcti)e and pre)enti)e -easures for the
identified de)iations.
/
/
/
&III4 RESEARCH R% (preferably done during post conferences)
/. %dentifies researchable proble-s related to labor and
deli)ery.
4. !tilize findings of research studies in intra<partal care.
4
4
I64 RECORDS MANAGEMENT RM%
/. "ocu-ents accurately rele)ant data about client.
4. Maintains and organized syste- of filing and +eeping records
of the client.
/
/
/. !tilizes appropriately all for-s of co--unicationE )erbal,
non<)erbal, electronic.
4. %nfor- client0s significant others of the progress of labor and
deli)ery.
5. $istens attenti)ely to clients and fa-ilies =ueries and
re=uests.
/
/
/
6I4 COLLABORATION AND TEAM$OR7 CT$%
/. Functions effecti)ely as a tea- player in the deli)ery
roo-*lying in.
4. Co--unicates the progress of labor*deli)ery to significant
others.
5. Establishes collaborati)e relationships ,ith -e-bers of the
health tea- and fa-ily -e-bers.
/
/
/
TOTAL SCORE :;;
s(
Se-4 CCC ?
n#
s(
Se-4 CCC ?
n#
s(
Se-4 CCC ?
n#
################################
###############################
###############################
"EAN
$icense Nu-ber1 ################# &alidity "ate1###########

IMMEDIATE CARE OF THE NE$BORN COMPETENC0
NE$BORN COMPETENCIES DESIRED
RATING
ACT/AL
RATING
/. Establishes and -aintain patent air,ay.
4. Puts the ne,born in rendelenburg Position.
5. Suctions -outh and nose of the ne,born gently.
6. "ries ne,born and ,raps ,ar-ly.
Places under droplight as needed
7. Perfor-s and interpret AP(AR scoring correctly.
%--ediately after deli)ery
After 7 -inutes
9. Ensures proper identification of ne,born ?na-e tag1 na-e of
-other, date and ti-e of deli)ery, gender and na-e of
attending physicianA.
C. Perfor-s physical assess-ent including anthropo-etric
-easure-ents including ,eight, height, head, chest, abdo-inal
circu-ference.
D. a+es )ital signs ?te-perature, per rectu- to chec+ patencyA.
F. (i)es oil*,ater and soap bath according to institutional
policy.
/> $atches ne,born to the -other0s breast i--ediately after
birth.
//. Applies CRE"E0S prophyla3is on the eyes.
/4. Perfor-s cord dressing aseptically.
"isinfects area properly according to hospital policy.
Cla-ps and cuts cord / inch fro- the abdo-en.
Chec+s for the presence of 4 arteries and / )ein.
"resses cord aseptically according to hospital policy.
/5. Ad-inisters &it. J ?/ -g*MA %nto the lateral anterior thigh or
)astus lateralis.
/6. Jeep baby ,rapped ,ar-ly under floor la-p or beside
-other according to institutional policy until discharge.
/7. Records pertinent obser)ations and nursing care done.
/9. Reports any signs of de)iation*abnor-ality to the
pediatrician.
5
/
4
/
4
4
4
6
/
/
/
/
/
/
/
/
/
/
/
/
4
4
/
II4 MANAGEMENT OF RESO/RCES! EN&IRONMENT AND E./IPMENT MRE%
/. Prepares instru-ents and e=uip-ents needed.
Suction bulb, cord cla-p, gauze, cotton balls,
disinfectant, blan+et, droplight, &ita-in J, anti-icrobial
ophthal-ic oint-ent.
4. Ensures use of sterile e=uip-ent during i--ediate care of
the ne,born.
5. Maintain ade=uacy of supplies as ne,born care is rendered.
6. Maintains orderliness of the ,or+ing area.
7. Obser)es precautionary -easures related to use of electrical
e=uip-ent.
9. Ensures a ,ar- and =uiet en)iron-ent.
C. !ses of supplies diligently.
D. Ensures proper disposal of hospital ,aste.
6
/
/
/
/
/
/
/
/. Pro)ides instructions to the -other on daily cord care and
pre)ention of cord infection.
4. Pro)ides discharge instructions to the -other on ,hen to
e3pect cord to fall off or to report signs of cord infection.
5. Pro)ides infor-ation regarding ne,born screening,
i--unization, feeding, etc.
6. Responds to =uestions of -other and relati)es regarding
e3pectations.
4
/
4
/
/. %dentifies ne,born by co-paring %" band ,ith data in the
chart.
4. "ocu-ents all pertinent data correctly and co-pletely.
5. Reports accurately any de)iations*abnor-al findings and
nursing inter)entions rendered.
6. Ensures the birth certificate and other ci)il registration for-s
are acco-plished*filled out according to institutional policy.
7. Perfor-s foot printing according to hospital policy.
4
/
/
4
/
&4 ETHICO-MORAL RESPONSIBIITIES EMR%
/. Respects the religious, cultural and ethnic practices of the
fa-ily of the ne,born.
4. Maintains pri)acy and confidentiality of findings of
/
/
assess-ents.
/. !pdates oneself ,ith the latest trends and de)elop-ents in
ne,born care.
4. Pro8ects a professional i-age of the pediatric nurse.
5. Accepts criticis-s and reco--endations.
6. Perfor-s functions according to standards.
/
/
/
/
/. %dentifies de)iation of practice fro- the standards.
4. Participates ?,hene)er possibleA in audit practices in the
nursery.
5. Reco--ends correcti)e and pre)enti)e -easures for the
identified de)iations.
/
/
/
&III4 RESEARCH R%
/. %dentifies researchable proble-s related to i--ediate care of
ne,born.
4. !tilizes findings of research studies in the i--ediate care of
the ne,born.
4
4
I64 RECORDS MANAGEMENT RM%
/. "ocu-ents accurately rele)ant data about ne,born.
4. Maintains an organized syste- of filing and record +eeping.
/
/
/. !tilizes appropriately all for-s of co--unicationE )erbal,
non<)erbal, electronic.
4. Maintains an open line co--unication ,ith the -other and
other fa-ily -e-bers.
5. %nfor-s -other of rele)ant infor-ation about ne,born.
6. $istens attenti)ely to =ueries and re=uests of -other and
fa-ily -e-bers.
/
/
/
/
/. Functions effecti)ely as a tea- player in the nursery.
4. Co--unicates findings of assess-ent to all concerned.
5. Establishes a collaborati)e relationship ,ith -e-bers of the
health tea- and fa-ily of the ne,born.
/
/
/
TOTAL SCORE @;
s(
Se-4 CCC ?
n#
s(
Se-4 CCC ?
n#
s(
Se-4 CCC ?
n#
####################################
$icense Nu-ber1 ################# &alidity"ate1###########
######################
#############################
"EAN
$icense Nu-ber1 ################# &alidity "ate1 ##########

NCM 107 - B / INTENSIVE NURSING PRACTICUM (INP)
PERFORMANCE RATING SCALE IN PRACTICING HEAD
NURSING(PHN)
NAME: _____________________________________________________YR. & SECTION: ___________
DATE OF EXPOSURE: _________________________AREA OF EXPOSURE:____________________
BEAVIOR D!"#$!% A&'()* REMAR+S
S&,$!
I. SAFE AND -UA.ITY CARE
Categorizes degree of patient care required
Identifies priority problems of patterns.
Transmits plan of care to the rest of nursing staff through:
1. Verbal reminders
2. Karde
!. "ndorsements
Coordinates plans #ith the medical team$ dietary department$
physical therapist$ social #or%ers etc.
Interprets role to patients$ families$ nursing staff$ and other
hospital personnel.
"nsures that ne# doctor&s orders are noted and carried out.
'emonstrates nursing procedures
Concerning diagnostic #or% ups$ super(ises:
)reparation and*or sending of patients to diagnostic units.
Collection and sending of specimen to appropriate places.
10
10
10
10
10
10

10

10
10
10
10
10
II. RECORDS MANAGEMENT
1. Chec%s records
Karde
)rogress notes
'iet lists
+lo# sheets
,ard report
Communication boo%
10
10
10
10
10
10
III. -UA.ITY IMPROVEMENT
-a%es rounds to obser(e effecti(eness of care.
.ffers assistance to staff.
'emonstrates competence and confidence in performing
nursing actions.
'isplays competence in the use of nursing process.
1/.,rites anecdotal reports 0at least once1. This should include:
2n ob3ecti(e description of the e(ent*acti(ity being
obser(ed.
2nalysis of e(ent*acti(ity
10
10
10
10
10
IV. .EGA. RESPONSIBI.ITY
'emonstrates gender sensiti(ity in patient care.
"nsures patient&s safety$ comfort and pri(acy.
Interprets hospital and #ard policies to students$
patients*families.
4eads memos and transmits them to staff as necessary.
+ollo#s policies and regulations of the:
5ospital*,ard
College of 6ursing
10
10
/
/
10
10
V. COMMUNICATION
17. "stablishes clear communications #ith nursing and
other disciplines regarding patient care.
Confers #ith the physician regarding the
diagnosis*response*non8response to
treatment*prognosis.
10
10
VI. CO..ABORATION AND TEAM0OR+
Initiates referral$ as necessary. 10
9oins the physician&s rounds.
Communicates #ith headnurse*nursing personnel
regarding patient care 0e.g.$ endorsements$ nursing
rounds1.
Confers #ith the other members of he health team.
1:. Considers the follo#ing in delegating functions*tas%s:
2bilities and s%ills
"(aluation of completed tas%s
10
10
10
10
10
VII. EA.T EDUCATION
)articipates in patient*#atcher orientation*education..
Conducts nursing rounds*bedside conference 0at least
once1
/
10
VIII.MANAGEMENT OF ENVIRONMENT1 RESOURCES AND
E-UIPMENT
"nsures the follo#ing:
Cleanliness of the area
2dequacy of appropriate:
a. ;upplies
b. <inens
2dequate functioning equipments
Chec%s attendance of personnel and ma%es the necessary
ad3ustments.
)lans schedule of .++ duties*(acation at least t#o #ee%s
in ad(ance
10
10
10
10
10
IX.RESEARC
Conducts staff de(elopment acti(ities: i.e. sharing of
current$ rele(ant literatures and research findings #ith the
staff.
10
2ccepts constructi(e criticisms and ma%es appropriate
changes.
=i(es constructi(e criticisms
'emonstrates self8direction
'iscerns bioethical implications #hen ma%ing decisions.
;ho#s compassion and commitment to the #elfare of the
indi(idual client and family.
'emonstrates honesty in data gathering$ problem
identification$ implementing inter(entions$ and e(aluating
outcomes.
'oes the right thing despite the consequences.
;tri(es for continuous impro(ement of self considering a
holistic perspecti(e
)ursues clients goals and ob3ecti(es in life.
'emonstrates critical thin%ing in (aried situations.
'emonstrates situational fleibility and adaptability.
2(ails self of opportunities for learning
10
10
10
10
10
10
10
10
10
10
10
10
XI. ETICO-MORA. RESPONSIBI.ITY
2ccepts the transcultural differences in health status among
social classes and bet#een cultural groups.
Integrates culture8based practices #ith professional modes of
inter(entions.
4ecognizes talents$ capabilities$ and potential of the +ilipinos.
;er(es the +ilipino people especially the poor and the
marginalized group.
Considers the multi8ethnicity of the +ilipino people.
10
10
10
10
10
;ets ob3ecti(es to direct acti(ities.
>tilizes a time plan for organization of acti(ities*efficiency
and economy of time and energy.
-aintains harmonious relationship #ith #ard personnel.
4eports to #or% punctually.
6otifies #ard if unable to report for duty.
2ppears neat and #ell groomed.
;ubmits requirements on time.
'isplays consistency of one&s beliefs and actions.
10
10
10
10
10
10
10
/
/
M#2#3(3 S&,$!: 451
M)6#3(3 S&,$!: 47/
1.00 470 - 47/ 8.8/ 49: - 4/9
1.8/ 479 - 47: 8./0 495 - 497
1./0 447 - 475 8.7/ 457 - 498
1.7/ 448 - 447 5.00 451 - 454
8.00 4/4 - 441
Comments: ????????????????????????????????????????????????????????
;ignature of ;tudent: ??????????????????????
;ignature of Teacher: ?????????????????????
'ate of "(aluation: ???????????????????????

NCM 107 - B / INTENSIVE NURSING PRACTICUM (INP)
PERFORMANCE RATING SCALE IN PRACTICING CLINICAL
INSTRUCTOR(PCI)
NAME: _____________________________________________________YR. & SECTION: ___________
DATE OF EXPOSURE: _________________________AREA OF EXPOSURE:____________________
BEAVIOR D!"#$!% A&'()*
S&,$!
REMAR+S
I. SAFE AND -UA.ITY CARE
Categorizes degree of patient care required
Identifies priority problems of patterns.
Transmits plan of care to the rest of nursing students and staff
through:
1. Verbal reminders
2. Karde
10
10
10
10
10
10
!. "ndorsements
Coordinates plans #ith the medical team$ dietary department$
physical therapist$ social #or%ers etc.
Interprets role to patients$ families$ nursing staff$ and other
hospital personnel.
"nsures that ne# doctor&s orders are noted and carried out.
'emonstrates nursing procedures
Concerning diagnostic #or% ups$ super(ises:
)reparation and*or sending of patients to diagnostic units.
Collection and sending of specimen to appropriate places.

10

10
10
10
10
10
II. RECORDS MANAGEMENT
2. Chec%s records
Karde
)rogress notes
'iet lists
+lo# sheets
,ard report
Communication boo%
10
10
10
10
10
10
III. -UA.ITY IMPROVEMENT
-a%es rounds to obser(e effecti(eness of care.
.ffers assistance to staff.
'emonstrates competence and confidence in performing
nursing actions.
'isplays competence in the use of nursing process.
1/.,rites anecdotal reports 0at least once1. This should include:
2n ob3ecti(e description of the e(ent*acti(ity being
obser(ed.
2nalysis of e(ent*acti(ity
10
10
10
10
10
IV. .EGA. RESPONSIBI.ITY
'emonstrates gender sensiti(ity in patient care.
"nsures patient&s safety$ comfort and pri(acy.
Interprets hospital and #ard policies to students$
patients*families.
4eads memos and transmits them to staff as necessary.
+ollo#s policies and regulations of the:
5ospital*,ard
College of 6ursing
10
10
/
/
10
10
V. COMMUNICATION
17. "stablishes clear communications #ith nursing and
other disciplines regarding patient care.
Confers #ith the physician regarding the
diagnosis*response*non8response to
treatment*prognosis.
10
10
VI. CO..ABORATION AND TEAM0OR+
Initiates referral$ as necessary.
9oins the physician&s rounds.
Communicates #ith headnurse*nursing personnel
regarding patient care 0e.g.$ endorsements$ nursing
rounds1.
Confers #ith the other members of he health team.
1:. Considers the follo#ing in delegating functions*tas%s:
2bilities and s%ills
"(aluation of completed tas%s
10
10
10
10
10
10
VII. EA.T EDUCATION
)articipates in patient*#atcher orientation*education..
Conducts nursing rounds*bedside conference 0at least
once1
/
10
VIII.MANAGEMENT OF ENVIRONMENT1 RESOURCES AND
E-UIPMENT
"nsures the follo#ing:
Cleanliness of the area
2dequacy of appropriate:
c. ;upplies
d. <inens
2dequate functioning equipments
Chec%s attendance of personnel and ma%es the necessary
ad3ustments.
)lans schedule of .++ duties*(acation at least t#o #ee%s
in ad(ance
10
10
10
10
10
IX.RESEARC
Conducts staff de(elopment acti(ities: i.e. sharing of
current$ rele(ant literatures and research findings #ith the
staff.
10
2ccepts constructi(e criticisms and ma%es appropriate
changes.
=i(es constructi(e criticisms
'emonstrates self8direction
'iscerns bioethical implications #hen ma%ing decisions.
;ho#s compassion and commitment to the #elfare of the
indi(idual client and family.
'emonstrates honesty in data gathering$ problem
identification$ implementing inter(entions$ and e(aluating
outcomes.
'oes the right thing despite the consequences.
;tri(es for continuous impro(ement of self considering a
holistic perspecti(e
)ursues clients goals and ob3ecti(es in life.
'emonstrates critical thin%ing in (aried situations.
'emonstrates situational fleibility and adaptability.
2(ails self of opportunities for learning
10
10
10
10
10
10
10
10
10
10
10
10
XI. ETICO-MORA. RESPONSIBI.ITY
2ccepts the transcultural differences in health status among
social classes and bet#een cultural groups.
Integrates culture8based practices #ith professional modes of
inter(entions.
4ecognizes talents$ capabilities$ and potential of the +ilipinos.
;er(es the +ilipino people especially the poor and the
marginalized group.
Considers the multi8ethnicity of the +ilipino people.
;ets ob3ecti(es to direct acti(ities.
>tilizes a time plan for organization of acti(ities*efficiency
and economy of time and energy.
-aintains harmonious relationship #ith #ard personnel.
4eports to #or% punctually.
6otifies #ard if unable to report for duty.
2ppears neat and #ell groomed.
10
10
10
10
10
10
10
10
10
10
10
10
/
;ubmits requirements on time.
'isplays consistency of one&s beliefs and actions.
/
M#2#3(3 S&,$!: 451
M)6#3(3 S&,$!: 47/
1.00 470 - 47/ 8.8/ 49: - 4/9
1.8/ 479 - 47: 8./0 495 - 497
1./0 447 - 475 8.7/ 457 - 498
1.7/ 448 - 447 5.00 451 - 454
8.00 4/4 - 441
Comments: ????????????????????????????????????????????????????????
;ignature of ;tudent: ??????????????????????
;ignature of Teacher: ?????????????????????
'ate of "(aluation: ???????????????????????
NAME OF S!"EN ############################ C$%N%CA$ AREA #######################
%NC$!S%&E "AE OF E'PER%ENCE ############### (RA"E ###############################
CLINICAL PERFORMANCE EVALUATION CHECKLIST
Postprtu! Cre of Mot"er n# Ne$%orn in Nor!l Stte
COMPETENC&'SKILL (ESIRE
(
SCO
RE
REMARKS
I) SAFE AN( *UALIT& NURSIN+ CARE ,S*C-
.) Utili/es t"e nursing pro0ess in t"e 0re of
$o!en n#
t"eir ne$%orn in t"e postprtu! perio# ,.1
points-
)* Assesses the client+s health status based on,
a) history -ndings 2 obstetrical history
2 course during labor
2 course during deli.ery
2 Apgar Scoring
b) physical 2 uterine contraction
2 .aginal bleeding
2 physiologic adaptation
2 .ital signs
2 ne/born re0e1es
2 re.ie/ of syste2s
c) psychological e1a2 3psychological adaptation4
d) results of diagnostic e1a2inations
e) socio 5 econo2ic and cultural factors
f) drug studies
)6 "e-nes physiological and psychological nursing
diagnosis in the follo/ing areas,
a) For !ot"er3 health perception7health
2anage2ent,
Nutrition72etabolic, eli2ination, acti.ity 5
e1ercise, sleep 5 rest, cogniti.e 5 perceptual, self
5 perception, self 5 concept, se1uality 5
reproducti.e, coping 5 stress, breastfeeding
proble2s)
b) For ne$%orn3 o1ygenation, ther2oregulation,
potential for infection, parenting proble2s)
6)8 Prioritizes nursing diagnosis
6)9 !tilizing appropriate technology and i2ple2ents
/ith the
Mother and signi-cant others nursing actions
based on
the NCP, 369 points4
a) pre.enting co2plications of deli.ery
3he2orrhage,
infection, hypother2ia, aspiration4
b) pro.iding proper nutrition 3postpartu2 diet4
c) pro2oting hygiene : co2fort in,
; bathing ne/born
; perineal care
; /ound care
; cord care
; breast hygiene
d) pro2oting eli2ination
e) perfor2ing postpartu2 e1cercises 3<E(A$
e1ercise,
chin to chest, =nee to chest, /al=ing4
f) pro2oting rest and sleep 3sleep 5 /a=e pattern
of
ne/borns, 2aternal fatigue4
g) enhancing 2aternal, paternal and fa2ily
adaptation
") postpartu2 chec= 5 ups
i) 2a=ing decisions for fertility control
4) resu2ption of se1ual acti.ities
5) understanding ne/born responses
6
.
.
.
.
.
.
.
.
.
6
6
6
6
7
1
6
6
.
.
.
.
.
6
6
6
6
6
.
6
.
.
II) MANA+EMENT OF RESOURCES8 ENVIRONMENT
AN( E*UIPMENT ,MRE-
a) !tilizing appropriate technology and other
resources in deli.ery of care
6
III) HEALTH E(UCATION ,HE-
a) (i.es health teachings for the 2others and
signi-cant others in ne/born care
6
IV) LE+AL RESPONSI9ILITIES ,LR-
)Pro.ides pri.acy, co2fort and safety at all ti2es) 6
V) ETHICO-MORAL RESPONSI9IITIES ,EMR-
a)Sho/s respect for di>erences in postpartu2 care
practices
b)Sho/s consideration for the 2other+s, ne/born
and
signi-cant other+s responses to inter.entions
6
6
VI) PERSONAL AN( PROFESSIONAL (EVELOPMENT
,PP(-
a)!tilizes7re?uests for super.ision /hen needed
b)Positi.ely accepts corrections and 2odi-es
actions7inter.entions based on corrections)
c)E.aluates o/n nursing perfor2ance based on
certain standards
6
.
.
VII) *UALIT& IMPROVEMENT ,*I-
a) Monitors7e.aluates client+s response7outco2es of
care)
6
VIII) RESEARCH ,R-
!ses updated re.ie/ of literature and research studies
to,
a) discuss current trends and issues in the care of
the
postpartu2 client and her ne/born)
6
I:) RECOR(S MANA+EMENT ,RM-
a) "e2onstrates accuracy and honesty in recording
and
reporting signi-cant -ndings, nursing diagnosis and
inter.entions
6
:) COMMUNICATION ,Co!-
a) %ntroduces self and addresses client using
preferred titles of respect

.
:I) COLLA9ORATION AN( TEAM;ORK ,CT;-
(e!onstrtes le#ers"ip'reltes e<e0ti=el> $'
ot"ers in
$or5
a) %denti-es role in a tea2 approach in health
pro2otion and 2aintenance)
b) Collaborates /ith health tea2 2e2bers in
pro.iding total patient care)
c) ti2ely referrals
.
.
6

TOTAL
?@
Stu#entAs Signture BBBBBBBBBBBBBBBBB
C)IAs Signture BBBBBBBBBBBBBBBBB
(te of E=lution BBBBBBBBBBBBBBBBBB
NCM .CC C$%N%CA$ PERFORMANCE E&A$!A%ON (RA"%N( S@SEM
Postpartu2 Care of a Mother and Ne/born in a Nor2al State
AB 5 AC D *)E
A6 5 A9 D *)6B
CF 5 A* D *)B
CC 5 CG D *)AB
C8 5 CB D 6)E
CE 5 C6 D 6)6B
BA 5 BF D 6)B
B9 5 BC D 6)AB
B* 5 B8 D 8)E
9F 5 BE D 9)E
H 9F D B
NAME OF S!"EN ############################ C$%N%CA$ AREA #######################
%NC$!S%&E "AE OF E'PER%ENCE ######################(RA"E ###############################
PERFORMANCE E&AL/ATION CHEC7LIST
COMM/NIT0 HEALTH N/RSING%
BEHA&IOR+S7ILL Desire# S'ore Re-"r,s
lI 4 SAFE AND ./ALIT0 N/RSING CARE S.C%
:4: For-ulates initial data base on the fa-ily.
1.1.1 Perfor-s physical e3a-ination correctly and ,ith
confidence.
1.1.2 Correlates PE findings ,ith other assess-ent data.
1.1.3 "iscri-inates bet,een nor-al and abnor-al findings.
1.1.4 !tilizes cues that support*are representati)e of the
proble-.
1.1.5 Categorizes infor-ation*cues that reflect
e3planations*inferences about the fa-ily0s health status
and causes*reasons for these conditions.
:4? %dentifies fa-ily nursing proble-s*diagnoses in a syste-atic
and logical -anner.
1.2.1 All e3isting proble-s are identified and reported.
1.2.2 Proble-s reflect the bloc+s*barriers to the fa-ily0s
assu-ption of the fa-ily health tas+.
1.2.3 Assess-ent done*shared ,ith the fa-ily.
:4B Prioritizes fa-ily nursing proble-s*diagnoses.
:4A For-ulates a fa-ily care plan ,ith the fa-ily.
1.4.1 Selects appropriate nursing actions.
1.4.2 "esigns a ti-e plan for action selected..
1.4.3 !tilizes a)ailable physical and professional resources.
?
:;
:;
:;
:;
:;
:;
:;
:;
>
:;
:;
:;
:;
II4 MANAGEMENT OF RESO/RCES! EN&IRONMENT AND
E./IPMENT MRE%
!tilizes a)ailable physical and professional resources.
Anticipates needs for future care.
:;
:;
4 He"l() (e"')ing (o in#i*i#u"l "n# f"-il5 -e-3ers "s 'lien(s

%dentifies health infor-ation needs of indi)idual and fa-ily.
"e)elops plan for health teaching based on identified needs
and characteristics of client*fa-ily.
%-ple-ents plan for health teaching.
a.!ses language understandable to client*fa-ily.
b.!ses e3isting and*or prepares appropriate and rele)ant
teaching -aterials.
E)aluates results of health teaching.
>
>
?
?
?
II&4 LEGAL RESPONSIBILITIES LR
Sho,s co--it-ent to the ,elfare of the fa-ily ?
&4 ETHICO-MORAL RESPONSIBIITIES EMR%
Sho,s a,areness of o,n feelings and reactions and their
effect on fa-ily*client
?
Accepts suggestion and constructi)e criticis-s.
Manifests self direction
Reports for duty*conference*consultation on ti-e.
?
?
?
E)aluates plan of care ,ith the fa-ily
!tilizes teacher0s super)ision effecti)ely.
"iscusses difficulties encountered.
See+s closer super)ision ,hen needed.
Sho,s acti)e participation in group conferences*,ard classes
:;
:;
:;
&III4 RESEARCH R%
"isplays critical thin+ing in the analysis of the health
proble-s of the client*fa-ily.
:;
64 RECORDS MANAGEMENT RM%
.
"ocu-ents care gi)en and client progress accurately
:;
Ma+es referral to appropriate health care facilities.
%-ple-ents the plan of care 8ointly ,ith the fa-ily
Coordinates ,ith other -e-bers of the health tea-
:;
:;
:;
TOTAL
MNP$ /D>
M'P$ 479
/.>> 46D : 479
/.47 45F : 46C
/.7> 45> : 45D
/.C7 44/ : 44F
4.>> 4/4 : 44>
4.47 4>6 : 4//
4.7> /F9 : 4>5
4.C7 /DD : /F7
5.>> /D> : /DC
Co--ents1 ########################################################
Signature of Student1######################
"ate of E)aluation1 #######################

NAME OF S!"EN ############################## C$%N%CA$ AREA#####################
%NC$!S%&E "AE OF E'PER%ENCE ################## (RA"E ############################
PERFORMANCE E&AL/ATION CHEC7LIST
HOSPITAL E6PERIENCE ALL LE&ELS%
Me#i'"l Surgi'"l Nursing
Dire'(ion: Encircle the score if the beha)ior*s+ill ,as de-onstrated. %ndicate re-ar+s, as needed.
BEHA&IOR+S7ILL SCORE REMAR7S
Assess health status.
Perfor-s physical e3a-ination
Correctly
;ith confidence
"ifferentiates bet,een nor-al and abnor-al findings
"etects abnor-alities in )ital signs
"eter-ines the significance of laboratory and diagnostic
findings to the current proble-s.
Pic+s out critical and essential data in nursing history
rele)ant to current situation.
%dentifies nursing diagnosis in a syste-atic -anner
Nursing diagnosis reflect hu-an response
Nursing diagnosis reflect conditions pri-arily resol)ed by
nursing inter)ention or therapy.
Nursing diagnosis reflect etiology as the focus of treat-ent
Correlates bet,een PE findings, nursing history,
diagnostic*lab e3a- results.
All e3isting nursing diagnosis are identified.
Nursing diagnosis specifies the defining characteristics.
Prioritizes nursing diagnosis
For-ulates care plan for priority nursing proble-.
"eter-ines the outco-e criteria
Selects appropriate nursing actions
Anticipates needs for future care )is a )is potential
proble-.
%-ple-ents care plan ,ith the client
"e)elops the self : -anage-ent capability of the client
Ensures safety, co-fort, pri)acy in rendering care
Pro)ides necessary curati)e -easures e.g. air,ay
-aintenance and o3ygenation, correct drug ad-inistration,
corrects fluid and electrolyte i-balance and ad-inisters
blood co-ponent, pro)ides peri : operati)e care.
%-ple-ents the plan of care 8ointly ,ith the client.
Perfor-s nursing procedures*acti)ities
;ith ease and confidence
Correctly
Syste-ically
Pro)ides after care
Re)ises care plan as needed
?
>
>
:;
:;
:;
:;
:;
:;
:;
:;
:;
>
:;
:;
?
>
>
>
>
>
>
>
>
>
>
>
II4 MANAGEMENT OF RESO/RCES AND EN&IRONMENT MRE%
!tilizes a)ailable physical M professional resources
!tilizes biobeha)ioral strategies ?e.g. -ind<body<spirit
paradig- M reflecti)e of holis-A
?
>
%n)ol)es the client in the details of the plan, as appropriate
Pro)ides health teachings about restorati)e*rehabilitati)e -easures e.g. dietary
regi-en, prescribed e3ercises, lifestyle -odification
>
>
>
Sho,s co--it-ent to the ,elfare of the client
&4 ETHICO MORAL RESPONSIBILITIES EMR%
"e-onstrates core )alue.
Sho,s honesty in data gathering, proble- identification,
i-ple-enting inter)entions, reporting, recording and
e)aluating outco-es.
Manifests consistency in beliefs and actions.
Sho,s sensiti)ity to social proble-s affecting the health
status of the clientele being ser)ed.
Considers the ethnic orientation of the client*fa-ily
"isplays critical thin+ing in the analysis of the health
proble-s of the client*fa-ily.
Practices bioethical principles in care
reats client ,ith respect
Maintains fidelity
Safeguards the right to pri)acy e.g. confidentiality and fa-ily
Sho,s co-passion for the client and fa-ily
"e-onstrates gender sensiti)ity in care
Considers a holistic perspecti)e of the client
"e-onstrates situational fle3ibility and adaptability
Models good health habit
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
&%.PERSONAL AND PROFESSIONAL DE&ELOPMENT PPD
"e-onstrates attributes of a future professional
Sho,s a,areness of o,n feelings and reactions and their
effect on fa-ily*client.
Accepts suggestion and constructi)e criticis-s
Manifests self direction
Reports for duty*conference*consultation on ti-e
Sub-its re=uire-ents on ti-e
Sho,s initiati)e in acti)ities
!tilizes teacher0s super)ision effecti)ely
"iscusses difficulties encountered
See+s closer super)ision ,hen needed
Sho,s acti)e participation in group conferences*,ard
classes.
?
?
?
?
?
?
?
?
?
?
:;
As appropriate, e)aluates plan of care, ,ith client using the outco-e criteria.
Accepts suggestion and constructi)e criticis-s
:;
?
&III4 RESEARCH R%
!tilizes research studies in i-ple-enting care
:;
Perfor-s accurate docu-entation and recording
"ata is accurate
"ata is co-plete
Sho,s honesty in docu-entation
On ti-e
:;
:;
>
>
A
64 COMM/NICATION
Establishes rapport ,ith the client
Addresses client ,ith preferred na-e
?
?
6I4 COLLABORATION AND TEAM$OR7 CTM%
Coordinates ,ith the other -e-ber of the health tea-
?
TOTAL SCORE B9@
GRADE E./I&ALENT
SCORING E./I&ALENT:
/.> 59> : 59D
/.47 575 : 57F
/.7> 569 : 574
/.C7 55F : 567
4.> 554 : 55D
4.47 547 : 55/
4.7> 5/D : 546
4.C7 4// : 5/C
5.> 5/>
Co--ents1 ########################################################
Signature of Clinical %nstructor1 ######################
"ate of E)aluation1 ########################
HEALTH ASSESSMENT
PROCESS RECOR(IN+ ,Pro#u0t E=lution-
N!e3 BBBBBBBBBBBBBBBBBBBBBBBBBB +roup3 BBBBBBBBBBBB Are3 BBBBBBBBBBBBBB
(te In0lusi=e3 BBBBBBBBBBBBBBBBBBB Clini0l Instru0tor3
BBBBBBBBBBBBBBBBBBBBBB
ITEMS SCOR
E
REMARK
S
I) he obIecti.es of the interaction are spe0iD0 and
!esur%le)
,6-
II) "escription of the conte1t under /hich the interaction
occurred
is %rief but 0on0ise'00urte)
,6-
III) Record of actual interaction re0ects the follo/ing,
Establishes rapport and trust /ith the client) ,.-
%denti-es e>ects of the techni?ues used /hether
positi.e or negati.e)
,6-
er2inates the interaction 0orre0tl> and
ppropritel>)
,.-
IV) Analysis of the interaction re0ects the follo/ing,
Recognizes appropriateness of therapeutic
co22unication techni?ues used)
,6-
%denti-es e>ects of the techni?ues used /hether
positi.e or negati.e)
,1-
"ocu2entation of analysis, /here pertinent) ,6-
(e=elop!ent of insig"t ,1-
V) E.aluation of the interaction is based on the obIecti.es) ,6-
TOTAL ,6
C-
Perfect Score, 6E
Passing Score, *6 3CEJ4
HEALTH ASSESSMENT
PRO(UCT EVALUATION OF PH&SICAL E:AMINATION
For each section of the physical e1a2ination, e.aluate /hether -ndings /ere
co2plete, accurate, and recorded correctly)
ITEMS
CRITERIA
A00ur
te
Co!ple
te
Re0or#
e#
Corre0tl
>
"e2ographic "ata
(eneral Appearance
&ital Signs
S=in
Kead
Eyes
Ears
Nose
Pharyn1
Mouth
Nec=
Chest and $ungs
Keart
Abdo2en
(enitoLurinary Syste2
Mac= and E1tre2ities
OA$,
Perfect Score, 9G
Passing Score, 6G)G 3CEJ4
Nursing Foun#tion Course ,NCM .CC'HEALTH ASSESSMENT-
PRO"!C E&A$!A%ON OF N!RS%N( K%SOR@
+or each section of the nursing history from belo#$ e(aluate the accuracy and
completeness of findings and #hether findings are stated correctly.
ITEMS
CRITERIA
A00ur
te
Co!pl
ete
Stte#
Corre0tl
>
A) Contains 0ler8 00urte8 and
0o!pre"ensi=e
%nfor2ation on the follo/ing,
"e2ographic "ata
Chief Co2plaint
Kistory of present illness
Past illness history
Fa2ily illness history
Kealth perception7Kealth
Manage2ent Patterns
Nutritional7Metabolic Pattern
Eli2ination Pattern
Acti.ity7E1ercise Pattern
Sleep7Rest Pattern
Cogniti.e7Perceptual Pattern
SelfLPerception7SelfLConcept Pattern
RoleLRelationship Pattern
Se1uality7Reproducti.e Pattern
Coping7Stress olerance Pattern
&alue7Melief Pattern
M) Recorded data 0orre0tl> in appropriate
for2s)
Perfect Score, 9G
Passing Score, 6G)G 3CEJ
CLINICAL PERFORMANCE RATING SCALE: HOSPITAL BASED ER! OPD "n# $ARD%
LE&EL I&%
D A
%. SAFE AND ./ALIT0 N/RSING CARE S.C%
re)"3ili("(ion4
Nursing 2istory
Physical Assess-ent
fra-e,or+.
care.
5
4
5
4
4
5
4
5
5
4
4
4
5
5
4
4
4
6
5
4
5
4
II4MANAGEMENT OF RESO/RCES! EN&IRONMENT AND
E./IPMENT MRE%
Adapts en)iron-ent to -a+e it conduci)e for healing*pleasing of the
patient.
4
4
/
/
&4 PERSONAL AND PROFESSIONAL DE&ELOPMENT PPD%
;ell groo-ed
/
/
4

4
/
/
&I4 ./ALIT0 IMPRO&EMENT .I%
!ses feedbac+*clinical super)ision to i-pro)e nursing care.
standards of care.
5
4
4
4
&II4 ETHICO-MORAL RESPONSIBILITIES EMR%
/
/
/
4
4
4
&III4 RESEARCH
4
64 COMM/NICATION
4
/
/
6I4 COLLABORATION AND TEAM$OR7
care
pre)ent illness.
the plan of care.
4
4
/
TOTAL SCORE />>
GRADE E./I&ALENT
Co--ents1 ########################################################
"ate of E)aluation1 #######################
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PNO-NONESCOST College of Nursing

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