BSN – Level II – NCM 100

Performance Checklist

Bag Technique

Name of Student: Score:

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Year/Section/Group/Number:
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Rate the student’s performance by checking the appropriate box using the following criteria:

5 - Demonstrate procedure properly and explains the correct rationale behind action
4 - Demonstrate procedure properly, correct rationale was not thoroughly explained
3 - Demonstrate procedure properly, no/ wrong rationale stated. Procedure not completely and
accurately done and correct rational was thoroughly explained
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

*Average mean shall be computed and multiplied by factor 20. The product shall be transmuted using the
table for 100 points. Passing cut-off score is 65%.

Criteria 5 4 3 2 1
IMPLEMENTATION
1. Make sure that the arrangement of the
contents are correct.
2. Lay paper on flat surface of either table,
chest or box, if none, use floor.
3. Place the bag left side of paper side.
4. Open bag and take out towel and soap.
5. Wash hands using pouring method
observing proper technique.
6. Remove from bag apron and put it on,
observing proper technique.
7. Remove from bag articles needed for
care.
8. Close bag.
9. Complete care and wash hands and
return article to bag.
10. Remove apron and place to bag.
11. Ask the family to dispose paper bag.
12. Record visit.

REMARKS:

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Student’s Signature Clinical Instructor’s Date
Printed Name & Signature