University of Perpetual Help System-Biňan Campus

Dr. Jose G. Tamayo Medical University

Sto.Nino, Binan Laguna

COLLEGE OF NURSING

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST

Concert: Staff Nursing
Area: GENERAL WARD

Name: ____________________________
Date: _____________________________
Year: ____ Section: ____ Group No. ___
Rating: _______________

Direction: Put a check on the skills observed / performed, of not please include
remarks on the space provided.

Legend:

5- Outstanding
4- Very Satisfactory
3- Moderately Satisfactory
2- Minimally Satisfactory
1- Unsatisfactory

A. KNOWLEDGE 5 4 3 2 1 REMARKS
1. Knowledge in gathering data
2. Knowledge of the different methods
used in physical assessment.
3. Adequate knowledge regarding normal
values and other laboratory results.
4. Identifies nursing problems of patient
and its cause.
5. Explains scientific principles behind
patient’s condition and management.
6. Knowledge in setting goals and
prioritization of patient’s needs.
7. Knows intervention to be given and
the rationale.
8. Knows the theories and rationale
behind nursing procedures being
implemented.
9. Knows the principle of drug
administration and its action.
10. Knowledge on how to relate nursing
interventions to outcomes.
Subtotal:
 B. SKILLS 5 4 3 2 1 Remarks
1. Checks, records and interprets
accurately the vital signs of assigned
patients.
2. Ability to manipulate and care for the
equipment.
3. Ability to collect specimens for the
laboratory examination.
4. Demonstrate skill in providing
comprehensive nursing care.
5. Performs nursing procedures with
maximum result with minimum time,
effort and materials at her/his level.
6. Implements nursing care according to
priorities.
7. Provides health teaching for patient
and his family as manifested by good
communication skill.
8. Coordinates with other members of
the health team with regards to patient’s
condition.
9. Ability to transcribe doctor’s order.
10. Records accurately patient’s
condition and nursing intervention.
Subtotal:

C. ATTITUDES AND VALUES 5 4 3 2 1 Remarks

1. Punctuality and regular in attendance.
2. Professionalism in uniform.
3. Honesty and sincerity.
4. Resourcefulness and creativity.
5. Sense of responsibility.
6. Initiative, Diligence and Industry.
7. Tolerance and Patience.
8. Polite and Respectful to self and
others.
9. Works harmoniously with others.
10. Aware and understands the needs
and emotions of others.
Subtotal:

________________________ _________________________
Student’s Signature Clinical Instructor

University of Perpetual Help System-Biňan Campus

 Dr. Jose G. Tamayo Medical University
Sto.Nino, Binan Laguna

COLLEGE OF NURSING

Name: ______________________________________ Date: _________________

Yr/Sec: _____________________________________ Group: ________________
Area: _____________________________________________________________
Clinical Instructor: ___________________________________________________

PERFORMANCE EVALUATION TOOL

(STUDENT HEAD NURSE TO STUDENT NURSE)
NUMERICA
QUANTITATIVE DESCRIPTION
L RATING
Carries out expected tasks in a very consistent
5 Outstanding
manner with minimal guidance and supervision
Carries out expected tasks in a consistent manner
4 Very Satisfactory
with minimal guidance and supervision
Carries out expected tasks in a moderately
3 Satisfactory consistent manner with frequent guidance and
supervision
Needs Carries out expected tasks in a rarely consistent
2
Improvement manner with close guidance and supervision
Does not carry out expected tasks even with close
1 Unsatisfactory
guidance and supervision

PERFORMANCE RATING
I. ASSESSMENT / PLANNING
1.1 Establishes rapport with subordinates
1.2 Able to involve patients in plan of care
1.3 Punctual and prompt in all activities
1.4 Able to maintain stability under pressure
1.5 Gathers data using interview, observation, records review
and reports
1.6 Formulates appropriate nursing care plan
1.7 Wears complete prescribed RLE uniform
II. IMPLEMENTATION
a. Carries out assigned tasks based on the criteria of
distribution of assignments
b. Follows principles of time management
c. Equipped with required paraphernalia for RLE
d. Observes proper channels of communication
e. Carries out plan of care, including:
A. Bedside Care
B. Administration of medications
C. Administration of treatments (nebulization, IVF)
f. Shows initiative in performing tasks
g. Accomplishes delegated tasks within prescribed time
frame
h. Provides psychological and spiritual support to patients
i. Accepts supervision and criticisms
j. Conducts appropriate health teachings
 III. EVALUATION
1. Notifies immediate superior about untoward situations or
conditions related to patient care in the area
2. Make revisions in the plan of care as necessary
3. Evaluates Nursing Care rendered
IV. ETHICOLEGAL CONSIDERATIONS
1. Demonstrates honesty at all times
2. Conducts self in a tactful manner
3. Keeps confidential patient information
4. Observes the PNA Code of Ethics
5. Guided by RA 9173
6. Observes the 11 Core Competency Guidelines

REMARKS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ACTUAL SCORE x 100 EVALUATED BY: ___________________________

Student Head Nurse
TOTAL SCORE

CONFORME BY: ____________________________

Student Staff Nurse

NOTED BY: ____________________________

Clinical Instructor
 University of Perpetual Help System-Biňan Campus
Dr. Jose G. Tamayo Medical University
Sto.Nino, Binan Laguna

COLLEGE OF NURSING

HEAD NURSE PERFORMANCE CHECKLIST

Name:_____________________________________Date:____________________
Yr/Sec: ____________________Group:_________ Rating: __________________
Area: _____________________________________________________________
Clinical Instructor:___________________________________________________

A. Knowledge 5 4 3 2 1
1. Applies as appropriate theory as a basis for
decision making in nursing practice.
2. Assesses staffs presenting symptoms to
determine a nursing diagnosis and plan of action
based on a medical expertise and knowledge.
3. Knowledge in communication, clarification and
interpretation of existing problems with staff and
nursing responsibilities.
4. Inform the staff of the likely causes of errors
defects and waste.
5. Suggest in which risk, errors, quality of problems
maybe reduce.
B. Attitude
1. Neat and well groomed. Adheres to dress code.
2. Punctual in reporting for duty
3. Complies with the code of ethics of the nursing
profession and upholds and implements school
rules.
4. Assist in training staff in particular by setting a
good example.
5. Promotion of professional responsibility,
accountability and behavior.
C. Skills
1. Provide leadership in the assessment, planning,
implementation, and evaluation of
comprehensive school health program.
2. Respond to the student/ staff medical
emergencies.
3. Instruct subordinates in appropriate method and
procedure in providing care.
4. Initiate and facilitate any steps necessary to
improve methods, equipments, materials and
condition in the work area for which they are
responsible.

Equivalent: ______________ Rating: ____________

Point
Grade Equivalent
scale
Carries out expected behavior in a very consistent
5 85 Excellent and independent manner with less supervision and
guidance.
Carries out expected behavior in a consistent and
Very
4 82-84 independent manner that requires minimal
Satisfactory
supervision and guidance.
Carries out expected behavior in rarely
3 79-81 Satisfactory independent manner requiring more supervision
and guidance.
Carries out expected behavior in rarely
2 75-78 Fair independent manner requiring close supervision
and guidance.
Needs
74 and Carries out expected behavior under close
1 improvemen
below supervision and guidance.
t
Name: ____________________________Yr/sec./Group#:_____________
Area: _______________________________________________________
Clinical Instructor: _____________________________________________

Scaling Interpretation

This evaluation is to determine and appraise the performance of the

staff according to their assign task. By writing the appropriate score in the
proper column denoting the extent to which the nurses performed these
functions.

Criteria for Grading

15% Decorum Attendance-------------------------------------------
20% Requirements-----------------------------------------------------
25% Quiz-----------------------------------------------------------------
40% performance------------------------------------------------------

_____________
Total 100%

Prepared By:
Rongavilla, Celistine L.
BSN IV – F / Group 24
 University of Perpetual Help System-Biňan Campus
Dr. Jose G. Tamayo Medical University
Sto.Nino, Binan Laguna

COLLEGE OF NURSING

PERFORMANCE CHECKLIST

KNOWLEDGE 5 4 3 2 1
1. Gathers data appropriately and completely,
then validating it focusing function
needing assistance support
2. Analyze and interpret collected data
3. Knows the correct way of doing physical
assessment.
4. Gives attention and synthesize the
significant laboratory findings
5. Knowledge in identifying nursing
problems and categorizing it according to
the patients need.
6. Knows the rationale behind every
intervention given for the care of the
patient.
7. Have knowledge in giving proper
instruction for medicine
a. classification
b. nursing responsibility
c. drugs and solution
8. Explain or discuss the report clearly and
able to answer question correctly.
9. Knowledge in preparation of patient for
any diagnostic procedure
10.Knows how to formulate an accurate
nursing care plan for particular cases.

SKILLS 5 4 3 2 1
1. Ability to give and respond to the care
needed by the patient
2. Perform procedure properly such as doing
physical assessment, taking VS, and
giving medication as ordered.
3. Able to provide or assist patient in
performance of activities of daily living
whenever needed.
4. Always guided in precautionary and
preventive measure in providing care to
the patient.
5. Able to give health teachings clearly to the
patient.
6. Communicate effectively in identifying the
 needs of the patient.
7. Properly handling an instance of
emergency situation.
8. Implement Nursing care plan appropriately
9. Reassesses patient to determine whether a
remodification of care plan is necessary.
10. Able to conduct discharged planning with
the patient, his family and significant
others.

Legend:
5 – Outstanding (85)
4 – Very Satisfactory (83-84)
3 - Moderately satisfactory (81-82)
2 – Minimally satisfactory (75-80)
1 – Unsatisfactory (74 and below)