Cebu Institute Of Technology – University
collegeofnursing
SUMMARY PERFORMANCE SELF EVALUATION ACHIEVING INTRA-OPERATIVE CARE
COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. 01, Series
2009
_____________________ _______________________ ____________________
Name of Student Signature Date & Time of Surgery
INTRA-OPERATIVE CARE COMPETENCIES DESIRED ACTUAL
RATING RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Utilizes the nursing process in the care of OR client: 4
a) Obtains comprehensive client’s information by checking
complete accomplishment of the preoperative
checklist/client’s chart. 4
b) Identifies priority needs of the client at the Operating Room. 4
c) Provides needed nursing interventions based on identified 2
needs.
d) Monitors client’s responses to surgery.
2. Promotes safety and comfort of patients inside the OR. 2
3. Performs the functions of the scrub nurse:
a) Performs surgical scrub correctly 4
b) Wears sterile gowns and gloves aseptically 2
c) Prepares surgical instruments, sponges, sutures, and other 2
supplies in functional arrangement
d) Hands instruments, sponges, sutures, and other needed 2
materials according to surgeon’s preference
e) Performs surgical count accurately 2
4. Performs the functions of the circulating nurse:
a) Anticipates the needs of the surgical team 2
b) Sets up the OR room and needed equipment 2
c) Receives client for surgery / endorses client post-operatively 2
d) Assists in skin preparation and draping of client 2
5. Administers medications and other health therapeutics safely 2
II. MANAGEMENT OF RESOURCES AND ENVIRONMENT
(MRE
)
1. Organizes work load to facilitate timely patient care 4
2. Utilizes adequate and appropriate resources to support the OR 2
team
3. Ensures functionality of OR resources 2
4. Maintains a safe environment at the OR by observing the 2
principles of asepsis
III. HEALTH EDUCATION (HE)
1. Implements appropriate health education activities to client 2
based on needs assessment
IV. LEGAL RESPONSIBILITIES (LR)
1. Adheres to legal and institutional protocols regarding informed 2
consent
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the rights of the OR client 2
2. Accepts responsibility and accountability for own decisions and 2
actions as an OR nurse
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Performs OR functions according to professional standards 4
INTRA-OPERATIVE CARE COMPETENCIES DESIRED ACTUAL
RATING RATING
2. Possesses positive attitude towards learning surgical and OR- 2
related knowledge and skills
VII. QUALITY IMPROVEMENT (QI)
1. Participates in quality improvement activities related to infection 2
control and successful OR operations
IX. RECORDS MANAGEMENT (RM)
1. Maintains accurate and updated documentation of patient care 2
X. COMMUNICATION (Comm)
1. Establishes rapport with patients, significant others and members 1
of the health team
2. Uses appropriate information mechanisms to facilitate 2
communication inside the OR and with other departments in the
hospital
XI. COLLABORATION AND TEAMWORK (CTM)
1. Collaborates plan of care with other members of the health team 2
TOTAL SCORE: 75
When graded RLE performed (Specify Academic Year and Semester):
Academic Year :_____________ 1st Semester ( ) 2nd Semester ( ) Summer ( )
Name of Clinical Instructor :_______________ Signature _________________________
Licensed Number :_______________ Validity _________________________
Verified True and Correct:
____________________________ ________________________
Signature over printed name of Signature over printed name of
Clinical Coordinator Dean
License Number:_________________________ License Number :_______________
Validity :_________________________ Validity :_______________
