Catanduanes Sate Colleges

COLLEGE OF HEALTH SCIENCES

Virac, Catanduanes

Performance Evaluation Checklist – NCM 119- RLE

LEADERSHIP AND STAFF NURSING

Name ______________________________________ Group/Block _______________

Ward: ____________ Date/Time of Exposure __________________ Ave.Grade______

Directions:
The following are criteria for evaluation of students in the clinical portion of the course.
Each area identifies certain competencies, which must be met by the students in order to achieve
the highest mark for that competency. Read each item carefully and rate your response as
described by the items using the scale below.
5 Outstanding Performs the expected competency in a consistent and
independent manner without guidance and supervision
(91-95%)
4 Very Satisfactory Performs the expected competency in a consistent
and independent manner requiring minimal guidance
and supervision (86-90%)
3 Satisfactory Performs the expected competency most of the time
requiring moderate guidance and supervision (81-
85%)
2 Fair Performs the expected competency from time to time
requiring moderate guidance and supervision (75-
80%)
1 Poor Does not perform the expected competency even
under close supervision (74% & below)

Competencies O VS S F P Remarks
5 4 3 2 1
I. NURSING ABILITY (70 %)
A. Planning/Organizing Patient Care
1. Formulates realistic goals/objectives
2. Divide and distribute nursing load by making good
assignment
3. Define and give clear assignment through conference
4. Formulate time management effectively
5. Assess needs/problems of patients comprehensively
6. Understand medical care for each patient and acquaint
team members with it
Preparing Assignment Sheet
7. Make a good assignment for team members by listing
their name, position, unit patient assignment
8. Conference time and topic to be discussed is indicated on
the assignment sheet
9. Assignment of staff is reflected in the organizational
chart showing their position, line of authority
relationship and responsibility
10. Define, clarify assignment, give all directions accurately
through pre-conference
11. Place assignment sheet in proper designated area
 Competencies O VS S F P Remarks
5 4 3 2 1
B. Directing and Evaluating Patient Care
1. Conduct time conference, pre-conference and post-
conference daily
2. Provide quality nursing care utilizing nursing process
3. Encourage team members to give health teaching
4. Receive reports from team members regarding patient’s
care and progress
5. Interpret and clarify doctor’s order and medical care to
team members
6. Make rounds with team/attending physician
3. Make rounds with team members in monitoring
progress of patient care
4. Plans, directs and assist bedside nursing care given to
patients
5. Assist other medical health care team in the treatment
and diagnostic procedures
6. Report any serious changes in patients condition
Conducting Team Conference
11. Conduct daily pre-conference for 15-20 minutes before
exposure to the clinical area
12. Facilitate reporting of patient’s condition, care and
progress by the students nurse handling the patient
13. Team members participate by giving suggestions for
14. Team leader utilizes every opportunity in conducting
health education to patients
Conducting Intershift Report
15. Accomplish daily intershift report and
kardex/endorsement accurately and promptly
16. All data are complete and neatly written
17. Name of patient are properly arrange and organized
according to units and nursing care to be rendered
18. Significant and relevant patient data are transferred
completely and accurately to endorsement record
19. Statistical report are accurately written, reported and
signed by the team leader
II. Personality and Attitude (30 %)
A. Grooming and Appearance
1. Carries uniform neatly and orderly
2. Conscious about professional behavior
3. Demonstrates professional behavior
B. Punctuality
1. Reports on and off duty on time
2. Completes all learning assignment on time (ocular
survey, interview, family care plan, etc.)
C. Sense of Responsibility
1. Readily accepts responsibility for tasks of the
assignment
2. Works affectively under pressure
3. Manage his/her time to the best advantage
D. Initiative for self-learning
1. Provides/obtains resources necessary to complete the
assigned tasks
Competencies O VS S F P Remarks
5 4 3 2 1
 2. Accepts accountability for seeking supervision and
guidance of C.I in completing the assigned tasks
3. Self-directive in gaining knowledge and in seeking new
learning experiences
E. Interpersonal Relationship
1. Client and Family
a. Treat client/family members with a professional
caring attitude
b. Shows concern to patient’s condition and welfare
2. Health Team
a. Establishes and maintain harmonious relationships
with members of the health team
b. Polite and Courteous
c. Shows professional behavior in dealing with them
3. Peers and Clinical Instruction
a. Cooperates and works with peers/classmates
b. Maintains professional relationship with the CI’s
c. Accepts suggestions and constructive criticism
gracefully and tries to improve
d. Assumers responsibility for her actions and
decisions

Score Transmutation (Leadership & Staff Nursing

1.0= 132 – 135 1.7= 104 – 107 2.4 = 76 - 79

1.1= 128 – 131 1.8= 100 – 103 2.5 = 72 - 75
1.2= 124 – 127 1.9= 96 – 99 2.6 = 68 - 71
1.3= 120 – 123 2.0= 92 - 95 2.7 = 64 -67
1.4= 116 – 119 2.1 = 88 - 91 2.8 = 60 -63
1.5= 112 – 115 2.2 = 84 - 87 2.9 = 56 - 59
1.6= 108 – 111 2.3 = 80 - 83 3.0 = 52 -55

SUMMARY OF GRADES

Criteria Percentage
1. Clinical Performance Evaluation 60 %
2. Summative Tests 20 %
3. Requirements/Projects 20 %
Total 100 % Ave. Grade:

C.I’s Remarks on Student’s Performance

___________________________________
___________________________________
___________________________________

_______________________

Student’s Signature
______________________________
Clinical Instructor