UNIVERSITY OF CEBU

College of Nursing

PERFORMANCE EVALUATION CHECKLIST

AREA: Pediatric Ward

Name of Student:
Year Level:
School Year:
Semester:
Inclusive Dates of Clinical Rotation:
Weight
Competencies 1 2 3 4 Score Remarks
(Excellent) (Average) (Below Average) (Poor)

I. Safe and Quality Nursing Care

1. Obtains pediatric history including developmental age, task,
immunization, and etc.
2. Check vital signs
3. Conducts physical assessment
4. Measures height and weight
5. Monitors intake and output
6. Monitors nutritional status of the patient
7. Monitors intravenous fluids
8. Ensures a safety environment
II. Management of Resources and Environment
1. Maintains a therapeutic environment
2. Identifies client's resource that caused in meeting health
needs
3. Checks proper functioning of equipments if applicable
4. Refer s malfunctioning equipment to appropriate unit
5. Adheres to policies, procedures and protocols on prevention
and control of infection
6. Observes proper waste disposal
III. Health Education
1. Teaches patient's/significant others about proper positioning
when breastfeeding
2. Teaches significant others about nutritional needs of patient
appropriate for age group
3. Provides discharge instructions as to feeding, bathing,
administration of ordered medications, appointment dates
for follow-up check-up.
4. Responds to questions of clients and relatives regarding
expectations
IV. Legal Responsibilities
1. Secures informed consent in all procedures
2. Reports accurately and honestly incidents that may
endanger patient
3. Recognizes own assets and liabilities as well as utilization
of coping mechanisms
4. Ensures proper identification of the patient
5. Documents all pertinent data accurately and completely
V. Ethico-Moral Responsibilities
1. Respects the religious, cultural, and ethnic practices of the
patient and family
2. Projects a professional image of a pediatric nurse
3. Renders nursing care consistent with the client's bill of
rights
4. Provides ethical basis for nursing actions and judgment
5. Reports unethical and immoral incidents to proper
authorities

Revised: January, 2014

VI. Personal and Professional Development

1. Identifies one's strengths, weaknesses/limitations

2. Behaves appropriately at all times

3. Demonstrates congruence of words and action

4. Demonstrates good manners and right conduct at all times

5. Listens to suggestions and recommendations

6. Assesses own performance against standards of practice

7. Adapts to changes willingly

8. Sets attainable objectives to enhance nursing knowledge
and skills
9. Applies learned information for the improvement of care

VII. Quality Improvement

1. Identifies appropriate quality improvement methodologies
for the clinical problems
2. Detects variation in a specific parameters such vital signs of
patient from day to day
3. Reports significant changes in clients'
condition/environment
4. Solicits feedback from the client and significant others
regarding care rendered
5. Encourages the client to verbalize relevant changes in
his/her condition

6. Performs daily check of clients' records/condition

7. Documents all nursing care and actions implemented

8. Gives an objective and accurate report on what was
observed rather than the interpretation of the event
9. Provides appropriate suggestions on corrective and
preventive measures

10. Communicates solutions with appropriate groups

VIII. Research

1. Specifies researchable problems regarding client care

2. Uses appropriate nursing strategiesto address identified

nursing problems of a particular client
3. Analyzes and interprets data gathered based on significant
findings
4. Applies possible solutions to the nursing problems
identified

IX. Records Management

1. Completes updated documentation of client care

2. Applies principles of record management

3. Monitors and improves accuracy, completeness and
reliability of relevant data

4. Makes record readily accessible to facilitate client care

5. Utilizes a record system or hospital information system

6. Maintains integrity, safety, access and security of records

7. Documents/monitors proper record storage, retention and

disposal
8. Observes confidentiality / privacy of the clients' records

9. Maintains an organized system of filing and keeping

clients' records in designated area
Revised: January, 2014
10. Follows protocol in releasing records and other patient
information

X. Communication
1. Creates trust and confidence
2. Spends time with the client/significant others and members
of the health team to facilitate interaction
3. Listens actively to clients' concerns/significant others and
members of the health team
4. Interprets and validates client's body language and facial
expressions
5. Utilizes effective channels of communication relevant to
client care management
6. Provides reassurance through therapeutic touch, warmth
and comforting words of encouragement
7. Utilizes informatics to support the delivery of healthcare
XI. Collaboration and Teamwork
1. Participates actively in client care management including
audit
2. Recommends appropriate intervention to improve client
care
3. Respects the role of other members of the health team
4. Maintains food interpersonal relationship with clients,
colleagues and other members of the health team
5. Refers clients to allied health team partners
6. Prepares accurate documentation for efficient
communication of services

Evaluation:

Comments:
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________________________________
Student's Signature

________________________________
Date

________________________________
C.I's Signature

Revised: January, 2014