FM-LPU-NRSG-03c
College of Nursing
Telephone No. (043) 723-0706 loc. 109 / 110
PERFORMANCE EVALUATION CHECKLIST
Nursing Care Management 112
MEDICAL WARD
Name of Student: _____________________________________________________________________________
Year / Clinical Group: __________________________ School Year: ______________________________
Semester / Term: __________ First Semester: __________ Second Semester: __________ Summer: __________
Inclusive Dates of Clinical Rotation: _______________________________________________________________
Legend:
2 Progress Acceptable (Performance is usually effective and efficient)
1 Needs Improvement (Progress in performance is too slow to judge satisfactorily; task performance
is not done properly for majority of the time)
KEY AREAS OF RESPONSIBILITY Pass Repeat REMARKS
I. SAFE AND QUALITY NURSING CARE (SO a)
1. Obtain client health history including personal, social and history of present illness.
2. Conduct comprehensive health assessment
3. Gather other data related to the health condition (laboratory and diagnostic)
4. Identify the client priority needs (Nursing Diagnosis)
5. Develop comprehensive client care plan maximizing opportunities for prevention of problems
and/or enhancing wellness response.
6. Explains intervention to client and family before carrying out to achieve identified outcomes
7. Implement nursing intervention
7.1 Perform bedside care
7.2 Perform specific nursing procedure
7.2.1 Vital signs monitoring
7.2.2 IV Therapy
7.2.3 Assisting ADL
7.3 Administer medication accurately to the client and conforms to the 11 rules in drug
administration
7.4 Assists in doctor’s rounds and carrying out doctor’s order with CI’s supervision
7.5 Provide emotional support to the client throughout hospital stay (NPI)
8. Monitor effectiveness of nursing interventions.
9. Evaluate patient condition and records and pertinent data accordingly.
10. Revise care plan based on expected outcomes.
II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (SO a)
1. Ensure a quiet and safe environment.
2. Use supplies diligently.
3. Adhere to policies, procedure, protocols in prevention and control of infection.
III. HEALTH EDUCATION (SO a)
1. Obtain learning information through NPI and analyze relevant information to identify learning
needs
2. Apply health education principles through health teaching
3. Considers client and family preparedness in the plan of care
4. Formulate discharge plan
IV. LEGAL RESPONSIBILITY (SO d)
1. Secure informed consent in all procedures / waiver of responsibility for refusal to undergo
treatment
2. Check the completeness of informed consent and other legal forms.
3. Render nursing care consistent with the client’s bill of rights.
V. ETHICO-MORAL RESPONSIBILITY (SO d)
1. Respect the religious, cultural and ethnic practices of the client and his/her family.
2. Ensure privacy of client
3. Ensure confidentiality of client’s records
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (SO e)
1. Project a professional image of a nurse.
2. Accept criticisms and recommendations
3. Demonstrates situational flexibility and adaptability.
4. Demonstrate punctuality in reporting to duty
VII. QUALITY IMPROVEMENT (SO d)
1. Identify deviation of practice from the standards.
2. Report significant changes in the client’s condition/environment to improve stay in the hospital
VIII. RESEARCH (SO i and j)
1. Submit case study written output
2. Present case during bedside discussion / during post conference
3. Present individual drug study before drug administration
FM-LPU-NRSG-03c
College of Nursing
Telephone No. (043) 723-0706 loc. 109 / 110
KEY AREAS OF RESPONSIBILITY Pass Repeat REMARKS
IX. RECORDS MANAGEMENT (SO b)
1. Accomplish accurate documentation in all matters concerning client care in accordance to the
standards of nursing practice.
2. Complete client’s clinical portfolio.
3. Complete synthesis journal (diary)
4. Observes confidentiality and privacy of the clients record.
X. COMMUNICATION (SO k)
1. Utilize therapeutic communication with the client and significant others.
2. Inform client of relevant information about the present condition,
3. Listen attentively to queries and requests of client and family members.
XI. COLLABORATION AND TEAM WORK (SO c)
1. Maintain good interpersonal relationship with clients, colleagues and other members of the
health team.
2. Refer clients to appropriate allied team members
3. Participate and contribute in group activities
EVALUATION EXAM
4 – Passed, 1 – Failed
Total Score:
Over-all Performance Rating ____________________
Remarks
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Evaluatee: Evaluator:
_________________________________ _____________________________________
Signature of Student Over Printed Name Signature of Clinical Instructor Over Printed Name
Date Date
__________________________ __________________________
