Evaluation Tool for

Bag Technique
Complete Name: ________________________________ Score: ________________
Year Level and Section: ___________________________ Date: _________________

Not
Criterion Done Remarks
Done
A. Attitude
1. Wears complete prescribed uniform (neat and well groomed)
2. Demonstrates initiative to learn and acknowledges criticisms and
suggestions.
B. Knowledge Competencies
3. States objective of the activity and gives the rationale of steps.
4. Uses appropriate terms and speaks in client’s level of
understanding. 
C. Skill Competency 
5. Upon arrival at the patient’s home, place the bag on the table lined
with a clean paper. The clean side must be out and the folded part,
touching the table.
6. Ask for a basin of water. Open the bag and take out the towel and
soap. Wash hands using soap and water. wipe to dry.
7. Take out the apron from the bag and put it on.
8. Put out all the necessary articles needed for specific care (ex. wound
care, Benedict’s test), Close the bag and place it in one corner of the
working area.
9. Proceed in performing the necessary nursing care and treatment.
10. After the treatment (hypothetical), clean all things that were used
and (perform hand washing as needed) Open the bag and return all
things that were used in their proper.
11. Remove apron, folding it away from the person, the soiled side in
and the clean side out. Place it in the bag,
12. Fold the lining, place it inside the bag and Close the bag.
13. Take the record and have a talk with the Mother. Write down all
the necessary data that were gathered, observations, nursing care and
treatment rendered. Give instructions for care of patients in the
absence of the nurse.
14. Make appointment for the next visit (either home or clinic as
needed)
15. Documentation, pertinent data like procedure given, date and time
etc..
Total

Rate the student from 1 to 4 where:

4 is very satisfactory: exhibits competency very
satisfactorily
3 is satisfactory: exhibits competency satisfactorily
2 is fair: exhibit competency fairly
____________________
1 is needs improvement: needs to improve
Student’s Signature
Raw Score
Grade _______%= --------------------------- x 60+40
30 ____________________
Evaluator