DE LA SALLE LIPA

COLLEGE OF NURSING
PERFORMANCE EVALUATION IN
PROFESSIONAL NURSING PRACTICE
(Head Nursing)

Name: Year / Section: Rating:

Hospital: Shift: Date of Exposure:
CRITERIA:

CORE COMPETENCIES – 70%

I. SAFE AND QUALITY PATIENT CARE – 20% 4.0 3.0 2.0 1.0 REMARKS
1. Obtain comprehensive client’s information.
2. Supervise and assist in conducting physical examination
3. Direct staff nurses in providing physical comfort/utilizing comfort
devices/techniques
4. Supervise staff nurses in nursing care based on client’s needs
5. Evaluates client’s response to interventions
II. MANAGEMENT OF RESOURCES AND ENVIRONMENT – 5% 1.0 0.75 0.5 0.25 REMARKS
1. Ensures availability, completion of materials needed for nursing
care
2. Observe protocol in the designated area of assignment
3. Maintains orderliness of the working area. Performs proper
disposal of hazardous and non-hazardous wastes
4. Ensures warm and quiet environment
5. Uses supplies diligently.
III. HEALTH EDUCATION – 10% 2.5 1.88 1.26 0.64 REMARKS
1. Provides health instruction to the clients, staff and significant
others the importance of a healthy community
2. Responds to the questions regarding health problems
3. Provides information regarding the management of their disease
condition within the scope of nursing
4. Conducts classes, group discussion and other activities related to
health concerns
IV. LEGAL RESPONSIBILITY – 10% 2.5 1.88 1.26 0.64 REMARKS
1. Applies the principle of autonomy.
2. Keeps confidential matters at all times.
3. Documents all pertinent data correctly and completely.
4. Affixes signature in all document and record needed by the
institution
V. ETHICO-MORAL RESPONSIBILITY – 10% 2.5 1.88 1.26 0.64 REMARKS
1. Respects the rights to privacy
2. Respects the rights to confidentiality
3. Respects the religious, cultural, and ethnic practices of the client
4. Adheres to the Nursing Code of Ethics
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT – 10% 2.0 1.5 1.0 0.5 REMARKS
1. Accepts criticism and recommendation
2. Performs functions according to standards
3. Shows interest in work by voluntary willingness to perform
assigned tasks
4. Observes punctuality and proper decorum
5. Wears neatly and completely the prescribed uniform
VII. QUALITY IMPROVEMENT – 5% 2.5 1.88 1.26 0.64 REMARKS
1. Performs quality care that conform to nursing practice
2. Identify deviation of practice from the standards
VIII. RESEARCH – 5% 2.5 1.88 1.26 0.64 REMARKS
1. Identify researchable problem related to maternal and pediatric
care
2. Collect and submit research study related to assigned case

IX. RECORDS MANAGEMENT – 5% 2.5 1.88 1.26 0.64 REMARKS

1. Endorse and allocate patient

2. Compilation of head nursing forms and activities

 X. COMMUNICATION – 10% 2.0 1.5 1.0 0.5 REMARKS
1. Communicates effectively with client and plans through receptive
listening in non-judgmental approach and allowing time for
responses
2. Maintains an open line of communication with the clients and staff
nurses
3. Accepts criticism constructively
4. Plans, direct and assist bedside nursing care given to the client
5. Interprets, validates and relate symptoms of illness to specific
behavior of the clients
XI. COLLABORATION AND TEAM WORK – 10% 2.5 1.88 1.26 0.64 REMARKS
1. Function effectively as a health team in the ward
2. Goes with the Doctors rounds regularly
3. Establishes collaborative relationship with members of the health
team
4. Works independently in collaboration with other members of the
health team

KNOWLEDGE – 30%.5marks
I. EXAM – 10% AVERAGE:
1. Pre-test
2. Post-test
I. REQUIREMENTS – 10%
1. Compilation and accomplishment of Head Nursing Forms
II. CASE STUDY – 10% SCORE:

Comments:

Strengths:

Weaknesses:

Attendance Record:

Tardiness Absence/s
Date # of Minutes Date Remarks

Conforme: Evaluated by:

________ ___________________________
Student’s Signature over Printed Name CI’s Signature over Printed Name
Date: ______ Date: ________