Republic of the Philippines

Bicol University
College of Nursing
Legaspi City

INTRAOPERATIVE CARE COMPETENCY EVALUATION CHECKLIST

Signature over Printed Name of Student: ___________________________________________

Criteria for grading:

5 Outstanding 95-100 Carries out nursing responsibilities in a very consistent

and independent manner with minimal guidance and supervision
4 Very Satisfactory 90-94 Carries out nursing responsibilities in a consistent and independent
manner but requires moderate guidance and supervision
3 Satisfactory 85-89 Carries out nursing responsibilities in a consistent and independent
manner with frequent guidance and supervision
2 Fair 80-84 Carries out nursing responsibilities with errors even with frequent
guidance and supervision
1 Needs Improvement 75-79 Does not carry out nursing responsibilities even under close
guidance and supervision

5 4 3 2 1
PROFESSIONAL COMPETENCY (50%)

I. SAFE AND QUALITY NURSING CARE (SQC)

1. Utilizes the nursing process in the care of OR client
a. Obtains comprehensive client’s information by
checking and ensuring complete accomplishment of
the preoperative checklist
b. Identifies priority needs of OR client preoperatively,
intraoperatively and postoperatively
c. Provides appropriate nursing interventions based on
identified needs
d. Monitors client’s responses to surgery.
2. Promotes safety and comfort of patients inside the OR.
3. Performs the functions of the scrub nurse
a. Wears OR attire and PPE properly
b. Performs surgical scrub correctly
c. Wears sterile gowns and gloves aseptically
d. Serves gowns and gloves to OR team aseptically
e. Prepares surgical instruments, sponges, sutures and
other supplies in functional arrangement
f. Hands instruments, sponges, sutures and other
needed materials according to surgeon’s needs and
preference
g. Performs surgical count accurately
4. Performs the functions of the circulating nurse
a. Anticipates the needs of the OR team
b. Assists OR staff nurse in setting up the OR room
and equipment and in preparing the needed
materials for surgery
c. Assists OR staff nurse in receiving client for
surgery and in endorsing client post-operatively
d. Assists surgeon in skin preparation of client
e. Documents the surgical procedure completely
5. Administers medications and other health therapeutics
safely as prescribed
II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)
1. Coordinates with clinical instructor in organizing work
load to facilitate timely patient care
2. Utilizes adequate and appropriate resources to support
the OR team
3. Ensures functionality of OR equipment/resources
4. Maintains a safe environment at the OR by observing
the principles of asepsis
III. HEALTH EDUCATION (HE)
1. Implements appropriate health education activities to
client based on needs assessment
IV. LEGAL RESPONSIBILITIES (LR)
1. Adheres to legal and institutional protocols regarding
informed consent
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the rights of the OR client
2. Accepts responsibility and accountability for own
decisions and actions as a student scrub/circulating
nurse

VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)

1. Performs OR functions according to professional
standards
2. Possesses positive attitude towards learning surgical and
OR-related knowledge and skills
VII. QUALITY IMPROVEMENT (QI)
1. Participates in quality improvement activities related to
infection control and successful surgical procedures
2. Identifies and reports variances in sterility and other
perioperative activities
VIII. RESEARCH (R) (preferably done during post conferences)
1. Disseminates results of perioperative-related research
findings to other members of the team
IX. RECORDS MANAGEMENT (RM)
1. Assists OR staff nurses in maintaining accurate and
updated documentation of patient care
X. COMMUNICATION (Comm)
1. Establishes rapport with patients, significant others and
members of the health team
2. Assists OR team in using appropriate information
mechanisms to facilitate communication inside the OR
and with other departments in the hospital
XI. COLLABORATION AND TEAMWORK (CTW)
1. Collaborates plan of care with other members of the
health team
PERSONAL ATTRIBUTES (20%)
1. Reports to clinical duty promptly & uses time
productively
2. Reports in prescribed uniform and PPE with complete
paraphernalia
3. Maintains proper grooming
3. Handles emergency situations confidently
4. Displays emotional stability/maturity
5. Respects clients and significant others, fellow students,
clinical instructors, hospital administrators and personnel
6. Keeps in confidence any personal information entrusted
to him/her
6.Takes responsibility for one’s own learning and
development
8. Shows loyalty to the nursing profession and institution
where he/she belongs
REQUIREMENTS (30 %)
1. Individual Case Conference
2. Nursing Care Plan
5. Case Analysis/Study
6. Case Presentation
6. Learning feedback
7. Others, specify _________________
Formula: RS/TS X 50+50=Grade
Summary of Evaluation

_____________________________
(Signature Over Printed Name of CI)