CLINICAL PERFORMANCE AND EVALUATION CHECKLIST

Name: Lagrosas, Jannah Joyce

Date: October 7, 2021
Year: III Section: C____ Group No. 6____
Rating: ________
Area: Geriatric Ward Clinical Instructor: Dr. Roberto C. Sombillo

PERFORMANCE EVALUATION TOOL

(STUDENT HEAD NURSE TO STUDENT NURSE)

NUMERICA QUANTITATIVE DESCRIPTION

L
RATING
5 Outstanding Carries out expected tasks in a very consistent manner with minimal
guidance and supervision.
4 Very Carries out expected tasks in a consistent manner with minimal
Satisfactory guidance and supervision.
3 Satisfactory Carries out expected tasks in a moderately consistent manner with
frequent guidance and supervision.
2 Needs Carries out expected tasks in a rarely consistent manner with close
Improvement guidance and supervision.
1 Unsatisfactory Does not carry out expected tasks even with close guidance and
supervision.

PERFORMANCE RATING
I. ASSESSMENT / PLANNING 30%
1.1 Establishes rapport with subordinates (4) 4
1.2 Able to involve patients in plan of care (4) 4
1.3 Punctual and prompt in all activities (4) 4
1.4 Able to maintain stability under pressure (4) 3
1.5 Gathers data using interview, observation, records review and reports (5) 4
1.6 Formulates appropriate nursing care plan (5)
1.7 Wears complete prescribed RLE uniform (4) 3
II. IMPLEMENTATION 40%
a. Carries out assigned tasks based on the criteria of distribution of 4
assignments (4)
 b. Follows principles of time management (4) 4
c. Equipped with required paraphernalia for RLE (4) 3
d. Observed proper channels of communication (3) 5
e. Carries out plan of care, including
A. Bedside care (3)
B. Administration of medications (4)
C. Administration of treatments (nebulization, IVF) (4)
f. Shows initiative in performing tasks (3) 4
g. Accomplishes delegated tasks within prescribed time frame (4) 4
h. Provides psychological and spiritual support to patients (4) 3
i. Accepts supervision and criticisms (3) 4
III. EVALUATION 15%
1. Notifies immediate superior about untoward situations or conditions
related to patient care in the area (5)
2. Make revisions in the plan of care as necessary (5)
3. Evaluates Nursing Care rendered (5)
IV. ETHICOLEGAL CONSIDERATIONS 15%
1. Demonstrates honesty at all times (2.5) 4
2. Conducts self in a tactful manner (2.5) 5
3. Keeps confidential patient information (2.5) 4
4. Observes the PNA Code of Ethics (2.5) 4
5. Guided by RA 9173 (2.5) 4
6. Observes the 11 Core Competency Guidelines (2.5) 5

REMARKS :
Ms. Lagrosas followed the principle of the assigned functional assessment to her.
______________________________________________________________________________
Still, it’s observable that they lack of communication skills and body language when
______________________________________________________________________________
assessing an older adult. But, it’s understandable because it’s their first time doing
______________________________________________________________________________
a demonstration that where we head nurses together with Sir Sombillo to give
advice and guide them
Kristopher John M. Jimenez
EVALUATED BY: ___________________________________________
ACTUAL SCORE X 100 STUDENT HEAD NURSE

TOTAL SCORE Jannah Joyce Lagrosas

CONFORMED BY: __________________________________________
STUDENT STAFF NURSE

Dr. Roberto C. Sombillo

NOTED BY: _________________________________________
CLINICAL INSTRUCTOR