________________________ _________________________ Student’s Signature Clinical

Instructor’ Signature University of Perpetual Help System-Binan Campus Dr. Jose

G. Tamayo Medical University Sto.Nino, Binan Laguna COLLEGE OF NURSING CLINICAL
PERFORMANCE AND EVALUATION CHECKLIST Area: OPERATING ROOM Name:_________________
___________
Date:_________________
Year___ Section___ Group Number___
Rating:_______________
Direction: Put a check on the skills observed / performed, of not please include
remarks on the space provided. Legend: 3- Is at a very satisfactory level. Has
thorough knowledge and understanding of the said case/topic. Could do and plan i
ntervention on his/her own. 2- At satisfactory level. Has enough understanding t
o handle the case but needs Careful guidance. 1- Needs to be reevaluated. Compet
ency is at an unsatisfactory level and needs to be reoriented on the subject/cas
e at hand. A. ASSESSMENT 10% Wt 3 2 1 Score Remarks 1. Obtains and analyzes pert
inent data concerning patient’s condition. 2 2. Determines and categorizes clini
cal assessment of the patient. 2 3. Interprets prudently the physician’s order.
2 4. Checks and accomplishes pre-operative checklist prior to surgical procedure
. 2 5. Assess patient’s physiological,
psychological and patient’s emotional
status.
2 Subtotal 10 B. PLANNING 4% Wt 3 2 1 Score Remarks 1. Formulates appropriate n
ursing diagnosis based from thorough patients assessment. 1 2. Rationalizes prin
ciples of aseptic technique. 1 3. Checks functionality of the operating
room / delivery room equipment such as
suction machine, cautery and OR lights.
1 4. Prepares and selects surgical supplies
concerning the patient’s surgical
procedure.
1 Subtotal 4 C. INTERVENTION 15% Wt 3 2 1 Score Remarks Pre – Operative Phase 1.
Identifies patient and verifies procedure to be done. 1 2. Secures consent. 1 3
. Checks for clearances (cardio-pulmonary
clearance, pedia clearance), diagnostic
procedures.
1 Intra – Operative Phase 1. Explains proper position for induction of anesthesi
a and operation to be performed. 2 2. Demonstrate proper aseptic/antiseptic
technique, sterile drapings and handling of
instruments.
2 3. Maintains sterility of the operating room and sterile field. 2 Post – Opera
tive Phase 1. Monitors vital signs immediately after the operation. 2 2. Evaluat
es patient’s recovery from anesthesia. 2 3. Discusses the emergency resuscitativ
e
devices, equipment and emergency drugs
in the recovery room.
2 Subtotal 15 D. EVALUATION 4% Wt 3 2 1 Score Remarks 1. Evaluates plan care aft
er applying necessary nursing interventions. 1 2. Discusses appropriate health t
eaching (sterile wound care) 1 3. Performs proper documentation and other import
ant details are needed. 1 4. Participates in activity during post- conference. 1
Subtotal 4 Grand Total 10 0 ________________________ _________________________
Student’s Signature Clinical Instructor’ Signature