STAFF NURSE PERFORMANCE EVALUATION SHEET

Name: ___________________________________________________ Date: __________________

Position: _____________________________________ Performance Period: __________________

Scoring guide:
5- Always 4- Most of the time 3- Sometimes
2- Seldom 1- Never N/A- Not Applicable

PART 1 PATIENT CARE COMPETENCIES

A cluster of key areas of responsibility which serves as the core of competencies which includes safe and
quality care, communication, collaboration and teamwork and health education.

I. SAFE AND QUALITY NURSING CARE 1 2 3 4 5

1. Demonstrates knowledge base on the health /illness status of individual
a. Identifies the health needs of the patients /groups
b. Explains the health status of the patients /groups
2. Provides sound decision making in the care of individuals / groups
considering their beliefs and values
a. Identifies the problem
b.Gathers data related to the problem
c.Analyses the data gathered
d.Selects appropriate action
e.Monitors the progress of the action taken
3. Promotes safety and comfort of patients
a. Performs age-specific safety measures in all aspects of patient care
b. Performs age-specific comfort measures in all aspects of patient care
4. Sets priorities in nursing care based on patients’ needs
a. Identifies the priority needs of patients
b.Analyses the needs of patients
c.Determines appropriate nursing care to be provided
5. Ensures continuity of care
a.Refers identified problem to appropriate individuals / agencies
b.Establishes means of providing continuous patient care
6. Administers medications and other health therapeutics
a. Conforms to the 10 golden rules in medication administration and
health therapeutics
7. Utilizes the nursing process as framework for nursing
7.1 Performs comprehensive and systematic nursing assessment
a. Obtains consent
b. Completes appropriate assessment forms
c. Performs effective assessment techniques
d. Obtains comprehensive client information
e. Maintains privacy and confidentiality
f. Identifies health needs
7.2 Formulates a plan of care in collaboration with patients and other
members of the health team
a. Includes patient and his family in care planning
b. States expected outcomes of nursing intervention
c. Develops comprehensive patient care plan
d. Accomplishes patient centered discharge plan
 7.3 Implements planned nursing care to achieve identified outcomes
a. Explains interventions to patients, his family before carrying
them out
b. Implements nursing intervention that is safe and comfortable
c. Acts according to clients’ health condition and needs
d. Performs nursing activities effectively and in a timely manner
7.4 Evaluates progress toward expected outcomes
a. Monitors effectiveness of nursing interventions
b. Revises care plan when necessary
8. Responds to the urgency of the patient’s condition
a.Identifies sudden changes in the patient’s health conditions
b.Implements immediate and appropriate intervention
TOTAL =

COMMENTS:_________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
II. COMMUNICATION 1 2 3 4 5
1. Establishes rapport with patients, significant others and members of the
health team
a.Creates trust and confidence
b.Listens attentively to client’s queries and requests
c.Spends time with the client to facilitate conversation that allows client to
express concerns
2. Identifies verbal and non-verbal cues
a. Interprets and validates client’s body language and facial expression

3. Utilizes formal and informal channels

a. Makes use of available visual aids
4. Responds to needs of individuals, family, group and community
a. Provides reassurance through therapeutic, touch, warmth and comforting
words of encouragement
b. Readily smiles
5. Uses appropriate information technology to facilitate communication
a.Utilizes telephone, mobile phone, email and internet, and informatics
b.Identifies significant others so that follow up care can be obtained
c.Provides “ Holding” or emergency numbers for services
TOTAL =

COMMENTS:_________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
III. COLLABORATION AND TEAMWORK 1 2 3 4 5
1. Establishes collaborative relationship with colleagues and other
members of the health team
a. Contributes to decision making regarding patients’ needs and
concerns
b. Participates actively in patient care management including audit
c. Recommends appropriate intervention to improve patient care
d. Respect the role of other members of the health team
 e. Maintains good interpersonal relationship with patients, colleagues
and other members of the health team
2. Collaborates plan of care with other members of the health team
a. Refers patients to allied health team partners
b. Acts as liaison / advocate of the patient
c. Prepares accurate documentation for efficient communication of
services
TOTAL =
COMMENT:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

IV. HEALTH EDUCATION 1 2 3 4 5

1. Assesses the learning needs of the patient and family
a. Obtains learning info. through interview, observation & validation
b. Defines relevant information
c. Completes assessment records appropriately
d. Identifies priority needs

2. Develops health education plan based on assessed & anticipated

needs
a. Considers nature of learner in relation to: social, cultural, political,
economic, educational and religious factors.

3. Develops learning materials for health education

a. Involves the patient, family, significant others and other resources
b. Formulates a comprehensive health education plan with the
following components: objectives, content, time allotment,
teaching-learning resources and evaluation parameters
c. Provides for feedback to finalize the plan

4. Implements the health education plan

a. Provides for a conducive learning situation in terms of time & place
b. Considers client and family’s preparedness
c. Utilizes appropriate strategies
d. Provides reassuring presence through active listening, touch, facial
expression and gestures
e. Monitors client and family’s responses to health education

5. Evaluates the outcome of health education

a. Utilizes evaluation parameters
b. Documents outcome of care
c. Revises health education plan when necessary

TOTAL =
COMMENT:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PART 2 EMPOWERING COMPETENCIES

A cluster of key areas of responsibility that mandate compliance to the standards of legal, ethico-moral-
spiritual responsibilities and personal and professional development.
 V. LEGAL RESPONSIBILITY 1 2 3 4 5
1. Adheres to practices in accordance with the nursing law and other
relevant legislation including contracts, informed consent.
a. Fulfils legal requirements in nursing practice
b. Holds current professional license
c. Acts in accordance with the terms of contract of employment and
other rules and regulations
d. Complies with required continuing professional education
e. Confirms information given by the doctor for informed consent
f. Secures waiver of responsibility for refusal to undergo treatment or
procedure
g. Checks the completeness of informed consent and other legal forms
2. Adheres to organizational policies and procedures, local and national
a. Articulates the vision, mission of the institution where one belongs
b. Acts in accordance with the established norms of conduct of the
institution / organization
3. Documents care rendered to patients
a. Utilizes appropriate patient care records and reports.
b. Accomplishes accurate documentation in all matters concerning
patient care in accordance to the standards of nursing practice.
TOTAL =

COMMENT:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

VI. ETHICO-MORAL RESPONSIBILITY 1 2 3 4 5

1. Respects the rights of individual / groups

a. Renders nursing care consistent with the patient’s bill of rights: (i.e.
confidentiality of information, privacy, etc.)

2. Accepts responsibility and accountability for own decision and actions

a. Meets nursing accountability requirements as embodied in the job
description
b. Justifies basis for nursing actions and judgment
c. Projects a positive image of the profession

3. Adheres to the national and international code of ethics for nurses

a. Adheres to the Code of Ethics for Nurses and abides by its provision
b. Reports unethical and immoral incidents to proper authorities

TOTAL =

COMMENT:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

VII. PERSONAL AND PROFESSIONAL DEVELOPMENT 1 2 3 4 5

1. Identifies own learning needs
a. Verbalizes strengths, weaknesses, limitations
 b. Determines personal and professional goals and aspirations
2. Pursues continuing education
a. Participates in formal and non-formal education
b. Applies learned information for the improvement of care
3. Gets involved in professional organizations and civic activities
a. Participates actively in professional, social, civic, and religious
activities
b. Maintains membership to professional organizations
c. Support activities related to nursing and health issues
4. Projects a professional image of the nurse
a. Demonstrates good manners and right conduct at all times
b. Dresses appropriately
c. Demonstrates congruence of words and action
d. Behaves appropriately at all times
5. Possesses positive attitude towards change and criticism
a. Listens to suggestions and recommendations
b. Tries new strategies or approaches
c. Adapts to changes willingly
6. Performs function according to professional standards
a. Assesses own performance against standards of practice
b. Sets attainable objectives to enhance nursing knowledge and skills
c. Explains current nursing practices, when situations call for it
TOTAL =
COMMENT:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

PART 3 ENABLING COMPETENCIES

A cluster of key areas of responsibility that provide support to the effective & efficient performance of the
patient care competencies which includes management of resources & environment & records management.

VIII. RECORDS MANAGEMENT 1 2 3 4 5

1. Maintains accurate and updated documentation of patient care
a. Completes updated documentation of patient care.
2. Records outcome of patient care
a. Utilizes a records system ex. Kardex
3. Observes legal imperatives in record keeping
a. Observes confidentially and privacy of the patient’s records.
b. Maintains an organized system of filing and keeping patients’ records in
a designated area.
c. Refrains from releasing records & other info. without proper authority.
TOTAL =
COMMENT:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
IX. Management Of Resources And Environment 1 2 3 4 5
1. Organizes work load to facilitate patient care
a. Identifies tasks or activities that need to be accomplished
b. Plans the performance of tasks or activities based on priorities
 c. Finishes work assignment on time
2. Utilizes resources to support patient care
a. Determines the resources needed to deliver patient care
b. Controls the use of supplies and equipment
3. Ensures functioning of resources
a. Checks proper functioning of equipment
b. Refers malfunctioning equipment to appropriate unit
4. Checks proper functioning of equipment
a. Determines tasks and procedures that can be safely assigned to other
member of the team.
b. Verifies the competency of the staff prior to delegating tasks
5. Maintains a safe environment
a. Observes proper disposal of wastes
b. Adheres to policies, procedures and protocols on prevention and
control of infection
c. Defines steps to follow in case of fire, earthquake and other
emergency situations.
TOTAL =
COMMENT:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

PART 4 ENHANCING COMPETENCIES

A cluster of key areas of responsibility that ensures excellent performance of the patient care competencies
which includes research and quality improvement.

X. QUALITY IMPROVEMENT 1 2 3 4 5
1. Gathers data for quality improvement
a. Demonstrate knowledge of method appropriate for the clinical problems
identified
b. Detects variation in the vital signs of the patient from day to day
c. Reports necessary elements at the bedside to improve patient stay at
hospital
d. Solicits feedback from patient & significant others regarding care
rendered
2. Participates in nursing audits and rounds
a. Contributes relevant information about patient condition as well as unit
condition and patient current reactions
b. Shares with the team current information regarding particular patients
condition
c. Encourage the patient to speak about what is relevant to his condition
d. Documents and records all nursing care and actions
e. Performs daily check of patients records / condition
f. Completes patients records
g. Actively contributes relevant information of patients during rounds thru
readings and sharing with others
3. Identifies and reports variances
a. Documents observed variance regarding patient care and submits to
appropriate group within 24 hours
b. Identifies actual and potential variance to patient care
c. Reports actual and potential variance to patient care
 d. Submits reports to appropriate groups within 24 hours
4. Recommends solutions to identified problems
a. Gives appropriate suggestions on corrective and preventive
measures
b. Communicates and discusses with appropriate groups.
c. Gives an objective and accurate report on what was observed rather
than an interpretation of the event.
TOTAL =

COMMENT:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

SUMMARY

POINTS EARNED TOTAL

 Patient Care Competencies
1. Safe and quality nursing care ________
2. Communication ________
3. Collaboration and teamwork ________
4. Health Education ________
 Empowering
5. Legal responsibility ________
6. Ethico-moral responsibility ________
7. Personal and professional development ________
 Enhancing
8. Record management ________
9. Management of resources and environment ________
 Enabling
10. Quality Improvement _________
11. Research _________
GRANDTOTAL

FINAL RATING: __________________________

STAFF NURSE PERFORMANCE EVALUATION SHEET
“11 KEY AREAS OF RESPONSIBILITIES”

SUBMITTED TO

MA. LUISA S. PARREÑAS, RN, RM, MAN, Ed.D.

Field Experience in Nursing Administration & Management

Professor

PREPARED BY

LISETTE GRACE B. UMADHAY, R.N.

NONESCOST Graduate School SY 2011-2012

Student

August 14, 2011