Document Code No.

CHS/BSN-CURR -RLEFORM-003a
Revision No. Effective Date Page No.
00 02.24.2023 1 of 2

APGAR SCORING SHEET

Patient’s Name:
AOG: Vital Signs
Date & Time of Delivery: Temperature:
Amniotic Fluid: Pulse Rate:
Presentation: Respiratory Rate:
Type of Delivery: Anthropometric measurements
Diagnosis: HC: _______ CC: _______
Complications: AC: _______ MAC: ______

Instructions:
Based on the APGAR Scoring Chart, rate the APGAR SCORE per criteria of assigned newborn.
Add all the scores for each criteria to get the total score. Write the nursing interventions based
on the total score. (5 points per criteria)

Newborn Patient’s APGAR Score:

Score
Criteria
1 minute after birth After 5 minutes
Appearance (Color)
Pulse (Hear Rate)
Grimace (Reflex Irritability)
Activity (Muscle Tone)
Respiratory effort
Total Score:
Nursing Intervention:
 Document Code No.
CHS/BSN-CURR -RLEFORM-003a
Revision No. Effective Date Page No.
00 02.24.2023 2 of 2

EVALUATION TOOL: APGAR SCORING

UNACCEPTABLE SATISFACTORY EXCEPTIONAL
REMARKS
(1) (3) (5)
Required Information The student does The student provides some The student provides
not provide the of the required information all the patient’s
patient’s data information
Criteria & Total APGAR Score With scores less With at least 9 correct With all 12 correct
2 points each criterion, 2 pts for than 9 answers answers
total.score for 1 min & 5 min
overall total: 12 pts
assessment
Nursing Intervention Intervention/s are Correct Intervention/s but Intervention/s (>5
not appropriate for lacking (3-5 interventions) interventions) are
the patient and does correct and
not solve the main appropriate for the
problem (<3 patient.
interventions)
Performance Tasks No aspect of work Has minimal aspects of work Has all the aspects of
meets the level of that meet the level of work that exceed the
expectation expectation level of expectation
Has errors, With some errors and Shows exemplary
omissions and mastery is not thorough performance and
misconception understanding
Total ___/20