Catanduanes State University

COLLEGE OF HEALTH SCIENCES

Virac, Catanduanes

Related Learning Experience

Performance Evaluation Checklist -

Name: _Group/Block _
School Year: _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)

O VS S F P
Competencies 5 4 3 2 1 Remarks
I. Nursing Ability (70%)
A. Assessment and Nursing Diagnosis
1. Identify needs and problems through:
a. Clinical Observation
b. Patient Interaction
c. Physical Assessment (IPPA)
2. Interview the family and/or significant others in
obtaining health history
3. Identify normal and abnormal findings based from:
a. Diagnostic, laboratory test results
b. Vital Signs
c. Clinical manifestations observed
4. Identify task of activities that need to be
accomplished based on priorities.
B. Planning
1. Formulates care plan based on assessment
conducted to assigned patient/s.
2. Formulates complete nursing diagnosis in PES format
(problem, etiology, signs and symptoms).
 O VS S F P
Competencies 5 4 3 2 1 Remarks
3. Formulates realistic and attainable goals based on nursing
diagnosis
3. Plans patient care activities based on priorities.
4. Determines the equipment and supplies needed for the
completion of any nursing tasks.
5. Plans health education to patient/s concerning:
a. Treatment modalities
b. Prevention of diseases
c. Promotion of health
C. Implementation
A. Nursing Care Interventions
1. Performs nursing procedure and other health
therapeutics with consideration for:
a. Safety and comfort
b. Accuracy/competence
c. Time
d. Patient’s rights
e. Resources available
f. Decision making
2. Responds to the urgency of patient’s condition.
3. Functions affectivity in an emergency and
stressful situation.
4. Conforms to the 10 Golden Rules in drug
administration demonstrating the skill in:
a. Calculation of dosage and solution
b. Giving of injection
c. Identifying the site of venipuncture
5. Carries out doctor’s order demonstrating skills in
decision-making and judgment
B. Records and Reports
1. Received all the necessary information of
patient’s condition upon endorsement.
2. Accurately records patient’s relevant
progress or changes.
3. Gives an objective and accurate report on what
was observed rather than interpretation
of the event.
4. Records administered medications on time.
5. Performs endorsement/change-of-shift report
comprehensively.
C. Evaluation
1. Evaluates the effectiveness of the total
nursing care based on the established
outcome criteria.
2. Evaluates patient’s responses and outcomes
to the therapeutic interventions through
frequent assessment and monitoring.
3. Identifies constraints to the attainment of the
outcome criteria.
4. Demonstrates critical thinking ability in
evaluating patient’s condition.
II. Personality and Attitude (30%)
A. Grooming and Appearance
 O VS S F P
Competencies 5 4 3 2 1 Remarks
1. Carries uniform, caps and shoes neatly and
orderly.
1. Conscious about professional appearance.
2. Demonstrates professional behavior.
B. Punctuality
1. Reports on and off duty on time.
2. Completes all learning assignment on time
(kardex, careplan, etc.)
C. Sense of Responsibility
1. Readily accepts responsibility for task of the
assignment.
2. Works effectively 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.
2. Accepts accountability for seeking supervision
and guidance of CI. In completing the assigned
tasks.
3. Self-directive in gaining knowledge and in
seeking new learning experiences.
E. Interpersonal Relationship
1. Patient and Family
a. Treat patient/family members with a
professional caring attitude.
b. Shows concern to patient’s condition and
welfare.
2. Health Team
a. Establishes and maintains harmonious
relationships with members of the health team.

b. Polite and courteous

c. Shows professional behavior in dealing with
them.
3. Peers and Clinical Instructors
a. Cooperates and works well with
peers/classmates
b. Maintains professional relationship with the
Clinical Instructor
c. Accepts suggestions and constructive
criticism gracefully and tries to improve.
d. Assures responsibility for her actions and
decisions.
 Score Transmutation

1.0 ----- 155 - 159.5

1.1 ----- 150.4 - 154.9
1.2 ----- 145.8 – 150.3
1.3 ----- 141.2 – 145.7
1.4 ----- 136.6 – 141.1
1.5 ----- 132 – 136.5
1.6 ----- 127.4 – 131.9
1.7 ----- 122. 8 –127.3
1.8 ----- 118.2 – 122.7
1.9 ----- 113.6 – 118.1
2.0 ----- 109 – 113.5
2.1 ----- 104.4 – 108.9
2.2 ----- 99.8 – 104.3
2.3 ----- 95.2 – 99.7
2.4 ----- 90.5 – 95.1
2.5 ----- 86.0 – 90.5
2.6 ----- 81.4 – 85.9
2.7 ----- 76.8 – 81.3
2.8 ----- 72.2 – 76.7
2.9 ----- 67.6 – 72.1
3.0 ----- 63.0 – 67.5

SUMMARY OF GRADES

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

C.I’s Remarks on Student’s Performance

Student’s Signature

Clinical Instructor