ARELLANO UNIVERSITY

College of Nursing

RLE - CLINICAL PERFORMANCE CHECKLIST IN STAFF NURSING

Staff Nurse Name: CECILIA DELLERA, RN

SKILLS (70%) 4 3 2 1
A. Utilization of nursing process
1. Utilizes the nursing process in the care of patients
1.1 Assesses needs of patient 4
1.2 Identifies/list down nursing diagnoses/problems 3
1.3 Utilizes a comprehensive total nursing care plan for assigned 4
patients
1.3.1 Plans nursing care considering the ff:
a. Patients comfort and safety 4
b. Priority problems 3
c. Medical care plan 4
d. Progress and response to treatment and nursing 4
care
1.3.2 Implements nursing interventions as planned
a. Demonstrates competence and confidence in 2
performing nursing interventions
b. Practices safety, comfort and privacy 4
c. Shows integrity in the implementation of standards 4
of nursing care
d. Acknowledges errors/mistakes as appropriate 4
e. Shows efficiency and economy of time and effort in 4
planning activities for the day
f. Implements discharge plans (home care, 4
medications compliance, intake precaution,
activities, follow up, diet regimen)
4
1.3.3 evaluates care rendered

2. Admits patient ensuring:

2.1 comfort and feeling of security 4
2.2 orientation to ward personnel, hospital set-up, policies and 4
various services
3. Establishes clear communications with nursing and other disciplines
regarding patient care:
 3.1 confers with the physician regarding the 4
diagnosis/response/non-response to treatment
3.2 Initiates referrals as necessary 4
3.3 Communicates with head nurse/nursing personnel regarding 4
patient care ( endorsements, nursing rounds, etc)
3.4 Confers with other members of the health team 4
4. Considers the 5 R’s in delegating functions 4
5. Records nursing care given 4
6. Ensures that the Kardex has completed entries at all times 4
7. Demonstrates nursing specific procedures as necessary 4
8. Guides others in the performance of nursing functions 4
9. Participates in nursing rounds/ bedside conferences 4
B. Demonstration of Professional and Personal Qualities
1. Identifies roles to patient, family and co-workers 4
2. Evaluates objectives for self-improvement 4
3. Shows consideration for the welfare of co-workers 4
4. Maintains harmonious relationship with unit personnel 4
5. Collaborates/communicates with the health team regarding unit 4
activities
6. Accepts delegated functions when necessary 4
7. Demonstrates situational flexibility and adaptability 4
8. Applies critical thinking in varied situations 4
9. Shows honesty and accuracy in data gathering, problem 4
identification, implementing interventions and evaluating outcomes
10. Identifies own capabilities and limitations 4
11. Accepts constructive criticisms and makes appropriate chnages 4
12. Avails self of learning opportunities 4
13. Follows policies and regulations of the hospital, unit and the college 4
of nursing
14. Reports to work punctually and regularly 4
15. Is neat and well groomed 4
 16. Submits requirements on time 3
17. Is conscientious and with pleasant work attitude 4

Total Performance grade 165

Performance Grade x 70%

Computation for the performance grade:

Step 1: Rate the Staff Nurse from 1-4 where:

4 is very satisfactory: exhibits competency independently

3 is satisfactory: exhibits competency with minimum guidance
2 is fair: exhibits competency with close supervision
1 needs improvement: did not exhibit competency
Step 2: to get the final grade for the above competency, compute the total score for items evaluated,
divide it by the highest total possible score for all items evaluated, multiply by 75, then add 25.

Performance = 96.9 x .70 = 67.8

KNOWLEDGE: (20%)

1. Nursing care plan -----------------50% Knowledge = total grade x 20%

2. Case study --------------------------20%
3. Drug study --------------------------10% Knowledge: 79 x 0.2 = 15.8
4. Journal Readings ------------------10%
Other requirements --------------10%
5. Written Examinations ----------- 10 %

ATTITUDE/ATTENDANCE (10%)

1. Attitude ------------------------------5% Attitude = grade x 5%

2. Attendance --------------------------5% = 100 x 0.05 = 5

Attendance = grade x 5%
= 100 x 0.05 = 5

Attitude/ Attendance = 10
 = Skills + Knowldege + Attitude/ Attendance
= 67.8 + 15.8 + 10
TOTAL GRADE = 93.6

Remarks: NEEDS TO WORK ON NCP

Charissa M De Leon, RN

Signature over Printed Name of Head Nurse Date 4/16/21

ARELLANO UNIVERSITY
College of Nursing

RLE - CLINICAL PERFORMANCE CHECKLIST IN STAFF NURSING

Staff Nurse Name: DIANA ROSE DOCTOLERO, RN

SKILLS (70%)
C. Utilization of nursing process
10. Utilizes the nursing process in the care of patients
10.1 Assesses needs of patient 4
10.2 Identifies/list down nursing diagnoses/problems 4
10.3 Utilizes a comprehensive total nursing care plan for 4
assigned patients
10.3.1 Plans nursing care considering the ff:
e. Patients comfort and safety 4
f. Priority problems 4
g. Medical care plan 4
h. Progress and response to treatment and nursing 4
care
10.3.2 Implements nursing interventions as planned
g. Demonstrates competence and confidence in 4
performing nursing u=interventions
 h. Practices safety, comfort and privacy 4
i. Shows integrity in the implementation of standards 4
of nursing care
j. Acknowledges errors/mistakes as appropriate 4
k. Shows efficiency and economy of time and effort in 4
planning activities for the day
l. Implements discharge plans (home care, 4
medications compliance, intake precaution,
activities, follow up, diet regimen)
1.3.3 evaluates care rendered 4

11. Admits patient ensuring:

11.1 comfort and feeling of security 4
11.2 orientation to ward personnel, hospital set-up, policies and 4
various services
12. Establishes clear communications with nursing and other disciplines
regarding patient care:
12.1 confers with the physician regarding the 4
diagnosis/response/non-response to treatment
12.2 Initiates referrals as necessary 4
12.3 Communicates with head nurse/nursing personnel 4
regarding patient care ( endorsements, nursing rounds, etc)
12.4 Confers with other members of the health team 4
13. Considers the 5 R’s in delegating functions 4
14. Records nursing care given 4
15. Ensures that the Kardex has completed entries at all times 4
16. Demonstrates nursing specific procedures as necessary 4
17. Guides others in the performance of nursing functions 4
18. Participates in nursing rounds/ bedside conferences
D. Demonstration of Professional and Personal Qualities
18. Identifies roles to patient, family and co-workers 4
19. Evaluates objectives for self-improvement 4
20. Shows consideration for the welfare of co-workers 4
21. Maintains harmonious relationship with unit personnel 4
22. Collaborates/communicates with the health team regarding unit 4
activities
23. Accepts delegated functions when necessary 4
24. Demonstrates situational flexibility and adaptability 4
25. Applies critical thinking in varied situations 4
26. Shows honesty and accuracy in data gathering, problem 4
identification, implementing interventions and evaluating outcomes
27. Identifies own capabilities and limitations 4
28. Accepts constructive criticisms and makes appropriate chnages 4
 29. Avails self of learning opportunities 4
30. Follows policies and regulations of the hospital, unit and the college 4
of nursing
31. Reports to work punctually and regularly 4
32. Is neat and well groomed 4
33. Submits requirements on time 4
34. Is conscientious and with pleasant work attitude 4

Total Performance grade 172

Performance Grade x 70%

Computation for the performance grade:

Step 1: Rate the Staff Nurse from 1-4 where:

4 is very satisfactory: exhibits competency independently

3 is satisfactory: exhibits competency with minimum guidance
2 is fair: exhibits competency with close supervision
1 needs improvement: did not exhibit competency
Step 2: to get the final grade for the above competency, compute the total score for items evaluated,
divide it by the highest total possible score for all items evaluated, multiply by 75, then add 25.

a. (172/172 x 75) + 25 = (100x75) + 25 =75 + 25 = 100

Performance = 100 x .70 = 70

KNOWLEDGE: (20%)

6. Nursing care plan -----------------50% Knowledge = total grade x 20%

7. Case study --------------------------20% 80 X 0.20
8. Drug study --------------------------10% Knowledge = 16
9. Journal Readings ------------------10%
Other requirements --------------10%
10. Written Examinations ----------- 10 %

ATTITUDE/ATTENDANCE (10%)

3. Attitude ------------------------------5% Attitude = grade x 5%

4. Attendance --------------------------5% = 10 x 0.05 = 5
 Attendance = grade x 5%
= 10 x 0.05 = 5

Attitude/ Attendance = 10

= Skills + Knowldege + Attitude/ Attendance

= 70 + 16 + 10
TOTAL GRADE = 96

Remarks: WORKS GREAT WITH OTHER STAFF NURSES EXCELLENT WITH HER REQUIREMENTS.

CHARISSA M. DE LEON, RN

Signature over Printed Name of Head Nurse Date 4/16/21

ARELLANO UNIVERSITY
College of Nursing

RLE - CLINICAL PERFORMANCE CHECKLIST IN STAFF NURSING

Staff Nurse Name: ANGELICA DUENAS, RN

SKILLS (70%)
E. Utilization of nursing process
19. Utilizes the nursing process in the care of patients
19.1 Assesses needs of patient 4
19.2 Identifies/list down nursing diagnoses/problems 4
19.3 Utilizes a comprehensive total nursing care plan for 4
assigned patients
19.3.1 Plans nursing care considering the ff:
i. Patients comfort and safety 4
j. Priority problems 4
k. Medical care plan 4
l. Progress and response to treatment and nursing 4
care
19.3.2 Implements nursing interventions as planned
m. Demonstrates competence and confidence in 4
performing nursing u=interventions
n. Practices safety, comfort and privacy 4
 o. Shows integrity in the implementation of standards 4
of nursing care
p. Acknowledges errors/mistakes as appropriate 4
q. Shows efficiency and economy of time and effort in 4
planning activities for the day
r. Implements discharge plans (home care, 4
medications compliance, intake precaution,
activities, follow up, diet regimen)
1.3.3 evaluates care rendered 4

20. Admits patient ensuring:

20.1 comfort and feeling of security 4
20.2 orientation to ward personnel, hospital set-up, policies and 4
various services
21. Establishes clear communications with nursing and other disciplines
regarding patient care:
21.1 confers with the physician regarding the 4
diagnosis/response/non-response to treatment
21.2 Initiates referrals as necessary 4
21.3 Communicates with head nurse/nursing personnel 4
regarding patient care ( endorsements, nursing rounds, etc)
21.4 Confers with other members of the health team
22. Considers the 5 R’s in delegating functions 4
23. Records nursing care given 4
24. Ensures that the Kardex has completed entries at all times 4
25. Demonstrates nursing specific procedures as necessary 4
26. Guides others in the performance of nursing functions 4
27. Participates in nursing rounds/ bedside conferences
F. Demonstration of Professional and Personal Qualities
35. Identifies roles to patient, family and co-workers 4
36. Evaluates objectives for self-improvement 4
37. Shows consideration for the welfare of co-workers 4
38. Maintains harmonious relationship with unit personnel 4
39. Collaborates/communicates with the health team regarding unit 4
activities
40. Accepts delegated functions when necessary 4
41. Demonstrates situational flexibility and adaptability 4
42. Applies critical thinking in varied situations 4
43. Shows honesty and accuracy in data gathering, problem 4
identification, implementing interventions and evaluating outcomes
44. Identifies own capabilities and limitations 4
45. Accepts constructive criticisms and makes appropriate chnages 4
46. Avails self of learning opportunities 4
 47. Follows policies and regulations of the hospital, unit and the college 4
of nursing
48. Reports to work punctually and regularly 4
49. Is neat and well groomed 4
50. Submits requirements on time 4
51. Is conscientious and with pleasant work attitude 4

Total Performance grade 172

Performance Grade x 70%

Computation for the performance grade:

Step 1: Rate the Staff Nurse from 1-4 where:

4 is very satisfactory: exhibits competency independently

3 is satisfactory: exhibits competency with minimum guidance
2 is fair: exhibits competency with close supervision
1 needs improvement: did not exhibit competency
Step 2: to get the final grade for the above competency, compute the total score for items evaluated,
divide it by the highest total possible score for all items evaluated, multiply by 75, then add 25.

b. (172/172 x 75) + 25 = (100x75) + 25 =75 + 25 = 100

Performance = 100 x .70 = 70

KNOWLEDGE: (20%)

11. Nursing care plan -----------------50% Knowledge = total grade x 20%

12. Case study --------------------------20% 82 X 0.20 =
13. Drug study --------------------------10% Knowledge: 16.4
14. Journal Readings ------------------10%
Other requirements --------------10%
15. Written Examinations ----------- 10 %

ATTITUDE/ATTENDANCE (10%)

5. Attitude ------------------------------5% Attitude = grade x 5%

6. Attendance --------------------------5% = 10 x 0.05 = 5

Attendance = grade x 5%
 = 10 x 0.05 = 5

Attitude/ Attendance = 10

= Skills + Knowldege + Attitude/ Attendance

= 70 + 16.4 + 10
TOTAL GRADE = 96.4

Remarks:

CHARISSA M. DE LEON, RN

Signature over Printed Name of Head Nurse Date 4/16/21