Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

NCM 109B: CARE OF MOTHER & CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

NAME:________________________________________________ DATE:_____________
SECTION & GROUP NO.___________________________________
CLINICAL AREA:_________________________________________
RUBRIC FOR NURSING DOCUMENTATION
(Applies to Sample Charting on Hospital Duties)
Please check on the score that best match your assessment of the student’s performance and compute
for grade based on the formula shown at the end of the evaluation table. The scoring shall observe the
following scores and their descriptions:

5 – Exemplary (Performance characteristic is observed at highest level and/or beyond expectations)

4.5 – Proficient (Performance characteristic is observed with mastery)

4 – Good (Performance characteristic is observed at average level)

3.5 – Poor (Performance characteristic is observed below the average or with minimal shortcomings)

3 – Very poor (Performance characteristic is observed erroneous and require further supervision)
Exemplary

Very Poor
Proficient

Good
No. Evaluation Criteria (Performance Characteristics) Rating
Poor
5 4.5 4 3.5 3
Clarity, Appropriateness and Organization
(20%)

Guide Descriptors
• Documentation is written legibly, clear and well
1 organized.
• Appropriate medical terminology is used
• Redundant (repetitious) words, phrases, and other
distracting information are omitted.
• Format follows a standard form with all necessary
components included and have logical flow.
Identifying Subjective-Objective Cues
(20%)

Guide Descriptors
• Noting of patient’s health status is fully explicated.
2
• Head-to-toe assessment is well observed and
noted.
• Assessment fully discusses health problem-
associated cues such as location, duration, timing,
severity or other features appropriate.
Planning and/or Rendered Care
(20%)
3
Guide Descriptors
• Plan and/or intervention noted shows exceptional
appropriateness for the diagnosis identified.

1
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan

NCM 109B: CARE OF MOTHER & CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

• Documented nursing care follows logical and

chronological order.
Consultation and Submission
(20%)
4
Guide Descriptors
• On-time consultation and submission of the draft
and final output for charting purposes.
Follow-up Notes
(20%)

Guide Descriptors
5
• All follow up orders (e.g. related to diagnostics,
prn meds, IVFs etc.) made by the MD carried out
and documented correctly and in chronological
order.
TOTAL GRADE
Note: Based on the needs of a particular activity, the guide descriptors can be a reference in full or
selectively chosen only as applicable.
Formula for Grade Computation:
Step 1: Compute for Criterion Grade Step 2: Compute for Total Grade

Raw Score x Criterion % = Partial Grade
5
Example (if computing grades for an NCP
with Assessment score of 4):
Assessment Criterion will be computed as,
4 (raw score) x 20 = 16%
5
Criterion 1 + Criterion 2 + and so on… = Total Grade
Example (if computing grades for an NCP):
NCP Grade = Assessment + Diagnosis +
Planning + Intervention +
Evaluation
= 16% + 20% + 20% + 12% + 20%
= 88%

________________________________________ _______________________________________
Printed Name & Signature of Student Printed Name & Signature of Clinical Instructor