COLLEGE OF NURSING
OPERATING ROOM PERFORMANCE EVALUATION TOOL
Name: Section/Group: Semester/SY:
Name of Affiliating Hospital: Area/Shift:
Date of Exposure: Name of CI :
Instruction: Check on the column of your choice as to what level is the performance of the student in the following procedures. Be guided
with the scoring indicated as follows:
Level of performance -
5 Competent (The student performs consistently in an effective & efficient manner)
4 Progress Acceptable (Performance is usually effective & efficient)
3 Progress Merely Acceptable (Performance is usually effective & efficient but not always )
Needs Improvement (Progress in performance is too slow to judge satisfactorily. Task performance is not
2
properly done most of the time)
Progress Unacceptable (No progress in performance has been demonstrated and/or performance is
1
consistent ineffective and inefficient)
NURSING PROCESS 5 4 3 2 1
KNOWLEDGE & SKILLS:
I. KNOWLEDGE (50)
1 Mastery of the patient’s case
2 Complete history and physical assessment
3 Identifies overt & covert problems and courses of action are feasible and appropriate
4 Communicates therapeutically and effectively with client’s family and co-workers
5 Performs therapeutic interventions properly
6 Charts comprehensively, concisely and accurately
7 Initiates pre-op and post-op teachings
8 Receives patient in the OR and prepares patient physically and psychologically
9 Prioritizes and organizes work activities
10 Evaluates result of interventions objectively
Total Points – I. Knowledge :
II. SKILLS(85) 5 4 3 2 1
1 Demonstrates correct techniques in the following procedures
1.1 Surgical Hand Scrubbing (complete method/short method)
1.2 Drying of Hands
1.3 Gowning
1.4 Gloving (open method/closed method)
1.5 Serving of Gown
1.6 Serving of Gloves
5 4 3 2 1
1.7 Drapes OR tables and trays with correct sterile technique
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1.8 Sets correct OR instruments and other gadgets appropriately
1.9 Serves instruments in proper and orderly manner
1.10 Handles instruments, sponges and other equipment and specimen properly
2 Observes the 12 principles of sterile technique at all times
3 Skillfully assists and anticipates needs during the entire surgical procedures
4 Records and reports relevant data promptly, legibly and intelligently
5 Executes accurately the physician’s legal order
Does after care of instruments, sponges, equipment and soiled linen after the surgical
6
operation
7 Does after care to the patient
8 Transfers patient to PACU/RR/WARD and endorsed accordingly
Total Points – II. Skills :
III. ATTITUDE : (36)
1. SENSITIVITY and CONCERN
1 2 3 4
Grouchy, no charisma, dull-hostile
to fellow workers, very little Moody, minimal response to the Good disposition, shows moderate Outstanding concern and
responsive to physical/ needs of clients, less caring, with concern and sensitivity, often sensitivity, exhibits empathy, very
emotional needs of patients and poor rapport with clients and emphatic, good rapport with clients good rapport with clients and
family, paranoid, unapproachable, fellow workers and fellow workers family, charismatic
“couldn’t care less” attitude
2. COOPERATION and HELPFULNESS
1 2 3 4
Very helpful to fellow workers,
No “Bayanihan” spirit, unwilling
Oftentimes reluctant to accept Willing to accept share of obliging, willing to accept share of
to accept share of responsibility,
responsibility responsibility responsibility, quick to extend
difficult to work with
help
3. PROFESSIONAL and PUBLIC RELATIONS
1 2 3 4
Intriguer, manipulator, Intriguer, manipulator,
discourteous, disliked, tactless and Often self-centered, shows discourteous, disliked, tactless and
Acceptable concern for people and
inconsiderate, disrespectful of minimal concern for others and inconsiderate, disrespectful of
authority
rights of others, rude to people authority rights of others, rude to people
even to superiors, smug attitude even to superiors, smug attitude
4. INTELECTUAL INTEGRITY
1 2 3 4
Intellectually honest in most
Intellectually dishonest, provides Demonstrates intellectual honesty
situations, occasionally withholds
misleading information meant to Demonstrates intellectual honesty even in difficult situations, accepts
information when confronted,
defend and protect self, does not and integrity, accepts limitations limitations and makes conscious
occasionally fails to accept
accept limitations. effort to improve on time.
limitations
5. MORAL/ETHICAL VALUES
1 2 3 4
Known to engage in an Highly ethical and morally
Demonstrates occasional lapses
unethical, immoral practices, Practices ethical and morally upright, provides excellent
in maintaining ethical and moral
inconsistent with norms and consistent with accepted norms example to peers and
uprightness
practice subordinates.
6. RELIABILITY and RESPONSIBILITY
1 2 3 4
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Performs duties promptly and
Irresponsible, unreliable, needs Usually prompt but performs
Perform duties promptly and efficiently without being
repeated reminders of just enough to get by, usually
efficiently without being reminded, is resourceful and
assignments, does less than dependable but sometimes needs
reminded innovative, takes initiative to
prescribed reminders of assignments
spend additional time
7. PRESCRIBED UNIFORM and PARAPHERNALIA
1 2 3 4
Occasionally with incomplete Complete and neat prescribed
Often incomplete prescribed
prescribed uniform and uniform and paraphernalia.
uniform and paraphernalia (more Complete and neat prescribed
paraphernalia (1-3) occasions. Always with prepared functional
than 4 occasions). Often untidy uniform and paraphernalia.
Sometimes with non-functional paraphernalia and maintain them
and non-functional paraphernalia
paraphernalia. in neat and orderly manner.
8. PUNCTUALITY and ATTENDANCE
1 2 3 4
Occasionally reports for duty
late (5-15 minutes) 1-2x during
Often late in attendance and Punctual in attendance and Often late in attendance and
the rotation, sometimes 1 day
submission of requirements submission of requirements submission of requirements
late in submission of
requirements 1-2 occasions
9. PARTICIPATION IN GROUP ACTIVIITIES
1 2 3 4
Actively participates in
Does not participate in any Participates in group activities Participates actively during
activities. Eager to share ideas
activities when called to do so activities
and learn from others.
Total Points – III. Attitude :
TOTAL POINTS I, II, III :
Computation of Grade :
Nursing Process 60% (Skills + Knowledge + Attitude)
Rotational Exam 25%
Requirements 15%
TOTAL : 100%
Name and Signature of Clinical Instructor I Date
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