I.

Profile of Respondents
Name: _________________________
Age: ____________________
Sex: ( ) Male ( ) Female
Civil Status: ( ) Single ( ) Married
IQ: ________
EQ: _______

CLINICAL PERFORMANCE CHECKLIST

1 2 3 4 5 Direction: Put a check

Delivery Room Very Needs Satisfactory Good Very in the appropriate box
Poor improve Good that corresponds to
ment your Level of
Confidence in the
1. Assesses physiological and
different clinical
psychological changes that occur
areas.
during pregnancy
2. Reviews briefly the body system
changes that occur during labor
and delivery
3. Identifies the landmarks and
diameters of the fetal skull and the
maternal pelvis
4. Discusses the role of the
components of labor: Passenger,
Passage and Powers
5. Discusses the goals and
techniques of prepared childbrth
6. Institutes clients comfort and safety
7. Participates in measures
designed to enhance the
process of labor and birth
8. Utilizes the nursing process to
address the common problems
experienced by a woman in
labor
9. Allows client to use techniques
to cope with pain experienced
during labor and birth
10. Adheres to practices in
accordance with the nursing law
and other relevant legislation
including contracts and
informed consent
11. Documents all data collected
and nursing actions taken as
result of data analysis
12. Emphasizes the importance of
providing spiritual care as a vital
aspect of nursing care
13. Discusses measures effective
in preventing and treating fetal
distress
14. Discusses the goals and
techniques prepared childbirth
15. States the guidelines that
should be followed for the
documentation of fetal
assessment data
16. Identifies areas related to labor
and birth that could benefit from
additional nursing research
17. Implements nursing care for the
family during labor
18. Portrays nursing skills in the
performance of different
procedures required of a
professional nurse
19. Communicates inner desire to
serve humanity despite
economic and social status of
the patient
20. Responds to individual, family
needs with care, compassion,
concern and dedication
 1 2 3 4 5
Operating Room Very Needs Satisfactory Good Very
Poor improve Good
ment
1. Obtains comprehensive clients
information by checking
preoperative checklist
2. Assess client’s condition and relate
to information obtained from the
chart
3. Transports client SAFELY from the
unit to the Operating room
4. Transfer client SAFELY from bed
to the stretcher; from stretcher to
the OR bed
1 2 3 4 5
5. Maintains functionality of all NICU Very Needs Satisfactory Good Very
contraptions such as IV infusion, Poor improve Good
indwelling foley catheter, chest ment
tube drainage, NGT 1. Washes hands well with soap and
6. Performs surgical hand scrub water
7. Prepares surgical instruments 2. Checks
in that all needed equipment
functional position and instruments are ready,
8. Performs appropriate action when available, clean, sterile, and in
surgical count is incorrect good working order.
9. Handles safely and correctly 3. Checks that all needed supplies
are ready and available.
specimens and tissues
4. Makes sure that the room is warm
10. Washes hands before entering (at least 25-28 °C/ 77.0-82.4 °F)
and re-entering the OR suite and free from drafts from open
11. Maintains aseptic technique
windows, doors, or fans.
throughout the procedure 5. Makes sure that all surfaces the
12. Documents nursing interventionswoman and baby will come in
contact with are clean, warm, and
13. Endorses client to appropriate unit dry.
postoperatively 6. Makes sure the room is well-lit
14. Prepares room/equipment based
on client’s surgical needs 7. Clamps and cuts the cord
approximately 2-3 minutes after the
15. Tests equipment for safety and baby’s birth or cessations of
proper functioning pulsation, whichever comes first.
16. Disinfects, washes and 8.packs Places the baby on the mother’s
instruments according to hospital chest in skin-to-skin contact.
policy
17. Reports malfunctioning equipment
and instruments to appropriate
authority
18. Participates in the preoperative
teaching plan
19. Responds to inquires of the client
regarding expectations
20. Identifies client by asking client (or
nearest kin if minor or
unconscious) to state his/her
name, surgical procedure to be
done, surgeon and operative site
21. Check the completeness of the
informed consent and other
documents contained in the chart
22. Identifies deviations of practices
from the standards of care of the
client in the Operating room
23. Recommends corrective and
preventive measures for the
identified deviations
24. Respects client’s religious and
cultural practices
25. Maintains privacy and
confidentiality of the client
26. Identifies risks and plans for the
patient care during and after
surgery and post-anesthesia
27. Evaluates the after effect of
anesthesia
28. Gathers new data and information
and recommends actions for
implementation
29. Portrays nursing skills in the
performance of different
procedures required of a
professional nurse
30. Communicates inner desire to
serve humanity despite economic
and social status of the patient