SCHOOL OF NURSING

General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

CLINICAL PERFORMANCE CHECKLIST (COMMUNITY HEALTH NURSING)

Direction: Competency
Please check the appropriate boxes below to describe verbalized or Level Comments
demonstrated competence level using the following criteria:
1 = Not yet Competent 2 = Competent 1 2
KEY AREAS OF RESPONSIBILITY AND CORE COMPETENCIES
I. SAFE AND QUALITY NURSING CARE
Demonstrated knowledge base on the health/ illness status of the client (family/
individual/ community/ population group) by identifying health needs. Incorporated
1      
prior learning into practice (previous knowledge/ skills: e.g. asepsis, anatomy and
physiology, theoretical concepts, etc.)
Utilized the nursing process as framework for nursing. Performed comprehensive
2      
and systematic nursing assessment, using appropriate assessment techniques.
Set priorities in nursing care based on clients’ needs. Analyzed data to identify
3 appropriate HEALTH PROBLEMS. Identified appropriate CLIENTs’ expected      
outcomes/ goals or objectives of care.
Provided sound decision making in the care of client (individuals/ families/ groups)
4      
considering their beliefs and values.
Formulated a plan of care in collaboration with clients and other members of the
health team. Developed comprehensive client care plan maximizing opportunities
5      
for prevention of problems and/or enhancing wellness response in collaboration
with client/s, with other members of the health team.
Promoted safety, comfort and privacy of clients by performing age-specific safety /
6      
comfort and privacy measures in all aspects of patient care.
Implemented planned nursing care to achieve identified outcomes by performing
7      
nursing activities effectively, safely, comfortably and in a timely manner.
Administered medications and other health therapeutics by conforming to the 10
8      
golden rules in medication administration and health therapeutics.
Evaluated progress toward expected outcomes by monitoring effectiveness of
9      
nursing interventions and revising care plan when necessary.
Ensured continuity of care by referring identified problem to appropriate
10      
individuals / agencies and establishing means of providing continuous patient care.
II. MANAGEMENT OF RESOURCES AND ENVRONMENT
Organized work load to facilitate client care by identifying tasks or activities that
11      
need to be accomplished.
Utilized financial resources to support client care. Determined the resources
12      
needed to deliver patient care; Controlled the use of supplies and equipment.
13 Established mechanism to ensure proper functioning of equipment      
Maintained a safe environment by observing proper disposal of wastes and
14 adhering to policies, procedures and protocols on prevention and control of      
infection.
III. HEALTH EDUCATION
Assessed the learning needs of the clients through interview, observation and
15      
validation and identifies priority needs.
Developed health education plan based on assessed and anticipated needs.
16 Considered nature of learner in relation to social, cultural, political, economic,      
educational and religious factors.
Developed learning materials for health education. Formulated a comprehensive
17 health education plan with the following components: objectives, content, time      
allotment, teaching-learning resources and evaluation parameters.
18 Implemented the health education plan.      

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 SCHOOL OF NURSING
General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

Direction:
Competency
Please check the appropriate boxes below to describe verbalized or Level Comments
demonstrated competence level using the following criteria:
1 = Not yet Competent 2 = Competent 1 2
KEY AREAS OF RESPONSIBILITY AND CORE COMPETENCIES
IV. LEGAL RESPONSIBILITY
Adhered to practices in accordance with the nursing law and other relevant
legislation including contracts, informed consent. Confirmed information given by
19 the doctor for informed consent. Checked the completeness of informed consent      
and other legal forms. Secured waiver of responsibility for refusal to undergo
treatment or procedure.
Adhered to institutional (organizational) policies and procedures, local and
20 national. Articulated the vision, mission of the institution where one belongs. Acted      
in accordance with the established norms of conduct of the institution.
Documented care rendered to clients. Utilized appropriate client care records and
21      
reports.
V. ETHICO - MORAL RESPONSIBILITY
Respected the rights of individual/groups. Rendered nursing care consistent with
22      
the student’s bill of rights. (i.e. confidentiality of information, privacy, etc.)
23 Accepted responsibility and accountability for own decision and actions.      
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT
Identified own learning needs. Verbalized strengths, weaknesses, limitations;
24      
Determines personal and learning goals and aspirations.
25 Pursued continuing education by participating in formal and non-formal education.      
Got involved in school organizations, social, religious and civic activities.
26      
Supported activities related to nursing and health issues.
Projected a professional image of the nurse. Conducted self in accordance with
(professional requirements); students’ guidelines and policies of UB. Demonstrated
27 good manners and right conduct at all times. Dressed appropriately by wearing the      
prescribed uniform for the assigned clinical area. Demonstrated congruence of
words and action.
28 Adhered to the University Student Confidentiality Policy.      
Adhered to School of Nursing Attendance Policy; Reported to clinical practice and
29 conferences on time. Participated in pre / post conferences; Turned in completed      
written assignments on time.
Possessed positive attitude towards change and criticism. Listened to suggestions
and recommendations, is not argumentative or defensive to constructive criticism.
30      
Tried new strategies or approaches; Adapted to changes willingly. Accepted
constructive criticism well and utilized suggestions for improvement.
Performed functions according to professional standards by: assessing own
performance against standards of practice; setting attainable objectives to enhance
nursing knowledge and skills; taking responsibility for the assigned client/s to level
31      
of student enrolment; seeking assistance/ guidance from peer/ RN/Clinical
instructor for additional care of client; and demonstrating cultural sensitivity and
cultural competence.
VII. QUALITY IMPROVEMENT
32 Gathered data for quality improvement.      
33 Identified and reports variances.      
34 Recommended solutions to identified problems.      

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 SCHOOL OF NURSING
General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

Direction:
Competency
Please check the appropriate boxes below to describe verbalized or Level Comments
demonstrated competence level using the following criteria:
1 = Not yet Competent 2 = Competent 1 2
KEY AREAS OF RESPONSIBILITY AND CORE COMPETENCIES
VIII. RESEARCH
35 Gathered data using different methodologies.      
36 Disseminated results of research findings.      
37 Applied research findings in nursing practice.      
IX. RECORDS MANAGEMENT
38 Maintained accurate and updated documentation of client care.      
X. COMMUNICATION
Established rapport with clients, significant others and members of the health
39      
team.
40 Identified verbal and non-verbal cues.  
41 Responded to needs of school children and teachers.  
42 Used appropriate information technology to facilitate communication.      
XI. COLLABORATION AND TEAMWORK
Established collaborative relationships with colleagues and other members of the
43      
health team.
44 Collaborated plan of care with other members of the health team.      
 TOTAL = 88 POINTS      

Name of Student: _____________________________ Section/ Group: ______________

Agency/ Ward: ______________________________ Shift: _______________________
Inclusive Dates: _____________________________

____________________________________________________
_
Name and Signature of Student

___________________________________________________ _______________________________________
_
Name and Signature of Clinical Instructor Date of Evaluation

Updated by:
SN Clinical Instructors

Noted by:

Helen D. Alalag, RN, MAN

Program Chair, BSN and HCS

Approved by:

Jocelyn A. Apalla, RN, MAN, MCD

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 SCHOOL OF NURSING
General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

Dean, School of Nursing

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