Republic of the Philippines

CAVITE STATE UNIVERSITY

(CvSU)

DON SEVERINO DE LAS ALAS CAMPUS

Indang, Cavite
(046) 415-0010 / (046) 415-0011
www.cvsu.edu.ph
cvsu.op206@gmail.com

COLLEGE OF NURSING

PERFORMANCE EVALUATION CHECKLIST FOR PRIMARY NURSING

AREA OF EXPOSURE-----------------------------------------------------------------------------------------------------
NAME ---------------------------------------------- DATE:------------------SECTION----------------GROUP-------
Direction: Please encircle the appropriate scores

TASK AND BEHAVIOR DESIRED ACTUAL REMARKS

SCORE
Utilize the elements of Primary Nursing in Patient care: (80%)
1. One to one nurse- patient relationship
1.1 Identifies role to:
 Patient 1
 Family 1
 Head nurse, Staff Nurses and other nursing personnel 1
 Physicians and other members of the health team 1
1.2 Provides direct care for 3-4 patients 10
1.3. Establishes a trusting relationship with patient family 5
2. Displays autonomy in providing direct patient care
2.1. Performs nursing activities with minimal supervision 10
2.2. Accounts for his/her own nursing decisions 10
2.3. Seeks supervision whenever necessary 5
3. Utilizes a comprehensive 24 hour total nursing care plan for
assigned patients
3.1. Assesses needs of patients through
 Nursing health history 10
 Physical Examination 10
 Other sources (chart, family, medical, nursing staff) 10
3.2. Identifies/ list down nursing diagnosis/ problems 10
3.3 Plans care from admission to discharge with the following
considerations:
a. Patient comfort/safety/privacy 10
b. Medical Care plan 5
c. Family and Community 1
d. Progress and response to treatment & nursing care 10
e. Quality of Life 1
f. Holistic Needs (Mind and Body-spirit) 5
g. Identifies priority problems 10
h. Prioritizes in-between patients 10
i. Identifies problems needing collaborative effort 10
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 j. Provides for preventive care 5
k. Provides for rehabilitative care 5
l. Discerns bioethical implications in decision making 5
m. Initiates discharge planning 10
3.4 Implements nursing intervention as planned by:
 Demonstrates competence and confidence in performing 10
nursing interventions
 Practices the following in the delivery of care:
o Safety 10
o Comfort 5
o Privacy 5
 Shows compassion and commitment to the welfare of the 10
individual client and family
 Demonstrate gender sensitivity to patient care 5
 Utilizes biobehavioral interventions in care 10
 Integrates culture based interventions in care 5
 Shows integrity in the implementation of standards of nursing 10
care
 Acknowledges errors/ mistakes as appropriate 10
 Follows –up patient progress from day to day 10
 Implements discharge planning 10
 Utilizes current readings in care of patients 5
 Modifies care as needed 10
3.5. Utilizes a time plan to implement care by:
o Reflects day to day nursing care activities 10
o Modifies time plan,as needed 10
o Shows efficiency and economy of time and effort in 10
planning activities for the day.
3.6 Evaluates care given 10
4. Establishes clear communications with nursing and other
disciplines regarding patient care
4.1. Confers with the physician regarding the diagnosis- 10
response/non-response to treatment/prognosis
4.2. Initiates referral, as necessary 10
4.3. Joins the physician rounds 10
4.4. Communicates with Head nurse and other nursing 10
personnel regarding patient care
4.5. Confers with other members of the health team 10
5. Records nursing care given in patients chart daily which reflects:
5. 1. Reflects relevant cues 5
5.2. problems 5
5.3. plans implemented 5
5.4. evaluation of care given 5
5.5. referrals and consultations with the health team 5
5.6 Ensures that the patient care is completely documented 10
using SOAP format
6. Ensures that the Kardex has completed entries at all times 10
reflecting the following:
6. 1. Profile/ Socio-demographic

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 6.2. Relevant data(special information)
6.3. Medications
6. 1. Treatments
6.2. Nursing Problems
6.3. Goals/ Objectives
6.7. Discharge plans
B. Professional and Personal Qualities(20%)
o Sets objectives for direction of activities 10
o Evaluates objectives for self-improvement 10
o Accepts constructive criticisms and makes appropriate changes 10
o Displays consistency in one’s beliefs and actions 10
o Recognizes talents, capabilities, and potentials of the Filipino 10
people
o Serves the Filipino people as well as the poor and the 10
marginalizes groups
o Shows sensitivity to transcultural differences and uniqueness 10
o Demonstrate honesty in data gathering, problem identification, 10
implementing interventions and evaluating outcomes
o Strives for continuous improvement of self considering a holistic 10
perspective
o Identifies own capabilities and limitations 10
o Follows policies and regulations of the hospital and CVSU-CON 10
o Reports to work/duty punctually 10
o Notifies ward and faculty if unable to report for duty 10
o Maintains a harmonious relationship with ward personnel 10
o Appears neat and well-groomed 10
o Submits requirements on time 10
o Conscientious and with pleasant work attitude 10

GRADING EQUIVALENT: Minimum Pass Level-278 & Maximum Pass Level- 371
1.00 361-371 2.25 306-316
1.25 350-360 2.50 295-305
1.50 339-349 2.75 284-294
1.75 328-338 3.00 273-283
2.00 317-327

ADDITIONAL REMARKS:

NAME & SIGNATURE ------------------------------------------------------------

DESIGNATION----------------------------------------------------------------------
DATE-----------------------------------------------------------------------------------

Revised 8/2022. jbd

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