S.G.R.
D COLLEGE OF NURSING
ASSIGNMENT
ON
TOPIC- CHECKLIST
SUBMITTED TO SUBMITTED BY
MRS. SONIA CHARANJIT KAUR
M.SC {N} 1 st YEAR
Signature of Student Signature of Evaluation
S.G.R.D COLLEGE OF NURSING
Clinical Evaluation Performa
Course – BSC {N} 1ST YEAR
Name of Student Date-
Ward-
SR.NO CLINICAL COMPETENCIES YES NO
1 Identification of needs before planning procedure
2 Arrangement of tray and articles of the procedure
3 Explanation of procedure before starting the procedure
4 Privacy was maintained
5 Follows the steps of procedure
6 IPR was maintained during procedure
7 Sterile technique were used
8 Articles were replaced after procedure
9 Unit was maintained
10 Hand washing at the end
11 Recording and Reporting of procedure
Signature of Student Signature of Evaluation
Signature of Student Signature of Evaluation