WESTERN MINDANAO STATE UNIVERSITY College of Nursing Normal Road, Baliwasan, Zamboanga City, Philippines Telephone No.

(062 !!2"0#$% & 'a( No. (062 !!2")2#* & +"mail, -n.wms/.ed/.ph & 0eb"1ite, www.wms/.ed/.ph
SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA PARTAL CARE COMPETENCY 2n 3--ordan-e with PRC Board o4 N/rsing 5emorand/m No. 0$ 1eries 200!

1ignat/re o6er Printed Name o4 1t/dent, 3-ademi- 7ear 8rad/ated, 9999999999999 Name o4 Patient (Patient:s initials only $st R;+, 9999999999999999999999 2nd R;+, 9999999999999999999999 #rd R;+, 9999999999999999999999 INTRAPARTAL COMPETENCIES I! SAFE AND "UALITY NURSING CARE #S"C$ $. Che-<s obstetri-al history in-l/ding parity, gra6ida s-ore, ;5P, +=C, 3>8, B>0, onset o4 tr/e labor. 2. Che-<s 6ital signs. #. Cond/-ts physi-al e(amination. ). Per4orms ;eopold:s mane/6er. %. Che-<s 'etal ?eart Rate and '/ndi- height. 6. 5onitor progress o4 labor & /terine -ontra-tions as to, 're@/en-y =/ration 2ntensity 2nter6al A. >bser6es 4or the timely r/pt/re o4 membrane. *. 2n4orm mother on pro-ess o4 labor. PERFORMS FUNCTIONS DURING ACTUAL LA(OR $. Transports -lients sa4ely while pro6iding pri6a-y. 2. Pla-es mother in lithotomy position. #. Per4orms perineal -are /sing sterile te-hni@/e -orre-tly. ). Per4orms proper hand s-r/b.
0ears gown and glo6es a--ording to hospital poli-y. Per4orms Ritgen:s mane/6er sa4ely. Coa-hes mother on breathing and p/shing te-hni@/es. =eli6ers baby and pla-enta -are4/lly. Che-<s and manages -ord re-oil -orre-tly Clamps and -/ts the -ord -orre-tly and sa4ely 2denti4y signs o4 pla-ental separation Che-<s the -hara-teristi- & -ompleteness o4 the pla-enta !. 3ssesses amo/nt o4 blood loss (Normal, B%00 -$0. +mploys inter6entions to a-hie6e and maintain a well -ontra-ted /ter/s to pre6ent & -ontrol hemorrhage. Cterine massage Corre-t administration o4 o(yto-in Cold -ompress $$. 3ssesses presen-e and degree o4 la-eration. $2. 3ssist in episiorrhaphy. $#. Che-<s siDe, -onsisten-y and lo-ation o4 /ter/s. $). Per4orms perineal -are and applies pad -orre-tly. $%. Pro6ides emotional s/pport to the mother thro/gho/t labor and deli6ery. $6. +6al/ates patient:s -ondition and re-ords pertinent data a--ordingly. $A. Prepares patient 4or trans4er to re-o6ery room & ward. II! MANAGEMENT OF RESOURCES) ENVIRONMENT AND E"UIPMENT #MRE$ $. Prepares room, instr/ments and e@/ipment needed. 1terile drape 1terile instr/ments and e@/ipment E'or-eps, s-issors, b/lb, syringe, ga/De, s/t/re, needle holder, -atheter (optional F Gelly pad 2. #. ). %. Per4orms steriliDation pro-ed/re 5aintains ade@/a-y o4 s/pplies as the deli6ery progresses. 5aintains orderliness o4 the sterile table. >bser6es pre-a/tionary meas/res related to /se o4 ele-tri-al e@/ipment. %. 6. A. *.
DESIRED RATING

1st RL E

2nd RL E

3rd RL E

ACTUAL RATING

% & ' ' ' ' ' ' ' & ' & & & &
& ' ' % ' & & ' ' % & & & & & & ' & & & & & & & &

6. A. *. !.

+ns/res a @/iet en6ironment Cses s/pplies appropriately Per4orm a4ter -are o4 the materials and e@/ipments /sed. +ns/res proper disposal o4 hospital waste in-l/ding blood and other 4l/ids.

& & & &

III! HEALTH EDUCATION #HE$ $. Tea-hes -lient on basi- preparation d/ring labor and deli6ery (can be done in the labor
room).

& ' ' & ' & & ' ' ' & & & & & & & & & &

2. #. ). %. 6.

Coa-hes: -lient on breathing & bearing down te-hni@/e. =emonstrates proper Hlat-h" onI breast 4eeding te-hni@/e (done post-partum period). 8i6es instr/-tions to parents regarding in4ant -are be4ore dis-harge (done post-partum period). Pro6ides dis-harge instr/-tions as to 4eeding, bathing, administration o4 ordered medi-ations, appointment dates 4or post natal and well baby -he-< /p (done postpartum period). Responds to @/estions o4 -lients and relati6es regarding e(pe-tations.

IV! LEGAL RESPONSI(ILITIES #LR$ $. 1e-/res in4ormed -onsent in all pro-ed/res related to labor and deli6ery. 2. Reports a--/rately and honestly the gender, time o4 deli6ery o4 the baby and the pla-enta. #. +ns/res proper identi4i-ation o4 the mother and newborn. ). =o-/ments all pertinent data -orre-tly and -ompletely. V! ETHICO MORAL RESPONSI(ILITIES #EMR$ $. Respe-ts the religio/s, -/lt/ral and ethni- pra-ti-es o4 the 4amily o4 the woman in labor and deli6ery. 2. Promotes emotional se-/rity by s/pporting needs. #. +ns/res pri6a-y and -on4identiality. VI! PERSONAL AND PROFESSIONAL DEVELOPMENT #PPD$ $. Cpdates onesel4 with the latest trends and de6elopment in labor and deli6ery. 2. ProJe-ts a pro4essional image o4 a deli6ery room n/rse. #. 3--epts -riti-isms and re-ommendations. ). Per4orms 4/n-tions a--ording to standards. VII! "UALITY IMPROVEMENT #"I$ (preferably done during post conferences) $. 2denti4ies de6iation o4 pra-ti-e 4rom the standard. 2. Parti-ipates in a/dit pra-ti-es in the deli6ery room & lying in. #. Re-ommends -orre-ti6e and pre6enti6e meas/res 4or the identi4ied de6iations. VIII! RESEARCH #R$ (preferably done during post conferences) $. 2denti4ies rersear-hable problems related to labor and deli6ery. 2. CtiliDe 4indings o4 resear-h st/dies in intra"partal -are. I*! RECORDS MANAGEMENT #RM$ $. =o-/ments a--/rately rele6ant data abo/t -lient. 2. 5aintains an organiDed system o4 4iling and <eeping re-ords o4 the -lient. *!COMMUNICATION #Co++$ $. CtiliDes appropriately all 4orms o4 -omm/ni-ationK 6erbal, non"6erbalK ele-troni-. 2. 2n4orm -lient:s signi4i-ant others o4 the progress o4 labor and deli6ery. #. ;istens attenti6ely to -lients and 4amilies @/eries and re@/ests. *I!COLLA(ORATION AND TEAMWOR, #CTW$ $. '/n-tions e44e-ti6ely as a team player in the deli6ery room & lying in. 2. Comm/ni-ates the progress o4 labor & deli6ery to signi4i-ant others. #. +stablishes -ollaborati6e relationship with members o4 the health team and 4amily members. TOTAL SCORECertified True and Correct:

' ' & & & & & & & &

&..

_________________________________ _________________________________ _________________________________ Clinical Instructor (1st RLE) Clinical Instructor (2nd RLE) Clinical Instructor (3rd RLE) License Number:_________________ License Number:_______________ License Number:_______________ PRC Card !alidit" #ate: __________ PRC Card !alidit" #ate: ________ PRC Card !alidit" #ate: ________

Noted b":

$%%ro&ed b":

'$R$( ') T$*P$N+ RN+ ,N+ #P$ RN+ ,N Clinical Coordinator License Number: 0150766 !C Card " #alidit$ Date: %anuar$ 17& '015 October (& '01'

LEIL$ #) -ENIT.+ OIC- DEAN License Number: 0106758 !C Card " #alidit$ Date:

WESTERN MINDANAO STATE UNIVERSITY College of Nursing Normal Road, Baliwasan, Zamboanga City, Philippines Telephone No. (062 !!2"0#$% & 'a( No. (062 !!2")2#* & +"mail, -n.wms/.ed/.ph & 0eb"1ite, www.wms/.ed/.ph
SUMMARY PERFORMANCE EVALUATION ACHIEVING IMMEDIATE CARE OF THE NEW(ORN COMPETENCY

2n 3--ordan-e with PRC Board o4 N/rsing 5emorand/m No. 0$ 1eries 200!

1ignat/re o6er Printed Name o4 1t/dent, 3-ademi- 7ear 8rad/ated, 9999999999999999 Name o4 Patient (Patient:s initials only $st R;+, 99999999999999999999999999999999 2nd R;+, 9999999999999999999999999999999 #rd R;+, 99999999999999999999999999999999 NEW(ORN COMPETENCIES I! SAFE AND "UALITY NURSING CARE #S"C$ $. 2. #. ). %. 6. A. *. !. $0. $$. +stablishes and maintains patent airway. P/ts the newborn in Prone position. =ries newborn and wraps warmly. Pla-es /nder droplight as needed. Per4orms and interprets 3P83R s-oring -orre-tly. 2mmediately a4ter deli6ery 34ter % min/tes +ns/res proper identi4i-ation o4 newborn (name tag, name o4 mother, date and time o4 deli6ery, gender and name o4 the attending physi-ian . Per4orms physi-al assesment in-l/ding anthropometri- meas/rements in-l/ding weight, height, head, -hest, abdominal -ir-/m4eren-e. Ta<es 6ital signs (temperat/re per re-t/m to -he-< paten-y ;at-hes newborn to the mother:s breast immediately a4ter birth. 3pplies CR+=+:s prophyla(is on the eyes. # 2 #
DESIRED RATING

1st RL E

2nd RL E

3rd RL E

ACTUAL RATING

2 2 2 ) 2 # # 2 2 2 2 # # 2

Per4orms -ord dressing asepti-ally. =isin4e-ts area properly a--ording to hospital poli-y Clamps and -/ts -ord $ in-h 4rom the abdomen Che-<s 4or the presen-e o4 2 arteries and $ 6ein =resses -ord asepti-ally a--ording to hospital poli-y 3dministers Litamin G ($ mg&5 into the lateral anterior thigh or 6ast/s lateralis. $2. Geeps baby wrapped warmly /nder 4loor lamp or beside mother a--ording to instit/tional poli-y /ntil dis-harge. $#. Re-ords pertinent obser6ations and n/rsing -are done.

$). Reports any signs o4 de6iation & abnormality to the pediatri-ian. II! MANAGEMENT OF RESOURCES) ENVIRONMENT AND E"UIPMENT #MRE$ $. 2. #. ). %. 6. A. *. Prepares instr/ments and e@/ipment needed. 1/-tion b/lb, -ord -lamp, ga/De, -otton balls, disin4e-tant, blan<et, droplight, 6itamin G, antimi-robial opthalmi- ointment, +ns/res /se o4 sterile e@/ipment d/ring immediate -are o4 the newborn. 5aintains ade@/a-y o4 s/pplies as newborn -are is rendered. 5aintains orderliness o4 the wor<ing area. >bser6es pre-a/tionary meas/res related to /se o4 ele-tri-al e@/ipment. +ns/res a warm and @/iet en6ironment. Cses s/pplies diligently. +ns/res proper disposal o4 hospital waste

) 2 2 2 $ 2 2 2

III! HEALTH EDUCATION #HE$ $. 2. #. ). Pro6ides instr/-tions to the mother on daily -ord -are and pre6ention o4 -ord in4e-tion Pro6ides dis-harge instr/-tions to the mother on when to e(pe-t -ord to 4all o44 or to report signs o4 -ord in4e-tion. Pro6ides in4ormation regarding newborn s-reening, imm/niDation, 4eeding, et-. Responds to @/estions o4 mother and relati6es regarding e(pe-tations. 2 2 2 $ 2 2 2 2 $ $ $ $ $ $ $ $ $ 2 2 2 $ $ 2 $ $ $ $ $ &..

IV! LEGAL RESPONSI(ILITIES #LR$ $. 2denti4ies newborn by -omparing 2= band with data in the -hart. 2. =o-/ments all pertinent data -orre-tly and -ompletely. #. Reports a--/rately any de6iations & abnormal 4indings and n/rsing inter6entions rendered. ). +ns/res that birth -erti4i-ate and other -i6il registration 4orms are a--omplished & 4illed o/t a--ording to instit/tional poli-y. V! ETHICO MORAL RESPONSI(ILITIES #EMR$ $. Respe-ts the religio/s, -/lt/ral and ethni- pra-ti-es o4 the 4amily o4 the newborn. 2. 5aintains pri6a-y and -on4identiality o4 4indings o4 assessments. VI! PERSONAL AND PROFESSIONAL DEVELOPMENT #PPD$ $. Cpdates onesel4 with the latest trends and de6elopment in newborn -are. 2. ProJe-ts a pro4essional image o4 the pediatri- n/rse. #. 3--epts -riti-isms and re-ommendations. ). Per4orms 4/n-tions a--ording to standards. VII! "UALITY IMPROVEMENT #"I$ $. 2denti4ies de6iation o4 pra-ti-e 4rom the standard. 2. Parti-ipates (whene6er possible in a/dit pra-ti-es in the n/rsery. #. Re-ommends -orre-ti6e and pre6enti6e meas/res 4or the identi4ied de6iations. VIII! RESEARCH #R$ $. 2denti4ies resear-hable problems related to immediate -are o4 newborn. 2. CtiliDes 4indings o4 resear-h st/dies in immediate -are o4 the newborn I*! RECORDS MANAGEMENT #RM$ $. =o-/ments a--/rately rele6ant data abo/t the newborn. 2. 5aintains an organiDed system o4 4iling and re-ord <eeping. *!COMMUNICATION #Co++$ $. CtiliDes appropriately all 4orms o4 -omm/ni-ationK 6erbal, non"6erbalK ele-troni-. 2. 5aintains an open line -omm/ni-ation with the mother and other 4amily members. #. 2n4orms mother o4 rele6ant in4ormation abo/t the newborn. ). ;istens attenti6ely to @/eries and re@/ests o4 mothers and 4amily members. *I!COLLA(ORATION AND TEAMWOR, #CTW$ $. '/n-tions e44e-ti6ely as a team player in the n/rsery. 2. Comm/ni-ates 4indings o4 assessment to all -on-erned. #. +stablishes -ollaborati6e relationship with members o4 the health team and 4amily o4 the newborn. TOTAL SCORE-

Certi4ied Tr/e and Corre-t,

_________________________________ _________________________________ _________________________________ Clinical Instructor (1st RLE) Clinical Instructor (2nd RLE) Clinical Instructor (3rd RLE) License Number:_________________ License Number:_______________ License Number:_______________ PRC Card !alidit" #ate: __________ PRC Card !alidit" #ate: ________ PRC Card !alidit" #ate: ________

Noted b":

$%%ro&ed b":

'$R$( ') T$*P$N+ RN+ ,N+ #P$ RN+ ,N Clinical Coordinator License Number: 0150766 !C Card " #alidit$ Date: %anuar$ 17& '015 October (& '01'

LEIL$ #) -ENIT.+ OIC- DEAN License Number: 0106758 !C Card " #alidit$ Date:

WESTERN MINDANAO STATE UNIVERSITY College of Nursing Normal Road, Baliwasan, Zamboanga City, Philippines Telephone No. (062 !!2"0#$% & 'a( No. (062 !!2")2#* & +"mail, -n.wms/.ed/.ph &0eb"1ite, www.wms/.ed/.ph SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA OPERATIVE COMPETENCY 2n 3--ordan-e with PRC Board o4 N/rsing 5emorand/m No. 0$ 1eries 200!

1ignat/re o6er Printed Name o4 1t/dent, 3-ademi- 7ear 8rad/ated, 99999999999999999 Name o4 Patient (Patient:s initials only $st R;+, 99999999999999999999999999999999 2nd R;+, 9999999999999999999999999999999 #rd R;+, 99999999999999999999999999999999 1st RL E 2nd RL E 3rd RL E

INTR$.PER$TI!E C.,PETENCE' (CIRC*L$TIN/ N*R'E)

#esired Ratin0

$&era0e Ratin0

I) '$1E $N# 2*$LIT3 N*R'IN/ C$RE ('2C) $)*tili4es t5e Nursin0 %rocess in t5e care of .)R) client 1) Obtains com*re+ensi,e client-s in.ormation b$ c+ec/in0 com*lete ') Accom*lis+ment o. t+e *reo*erati,e c+ec/list1clients c+art)
2) 3a/es sure t+eater is clean 4) ro,ides a clean /ic/ buc/et and *ail

5) Identi.ies *riorit$ needs o. t+e client u*on admission to t+e O*eratin0 !oom

2 2 6

6)

ro,ides needed nursin0 inter,entions based on identi.ied needs) 1) atient trans.er to stretc+er) ') atient trans.er to O)!) table 2) Alla$ *atient-s an5iet$ 6 7uestions)

1 1 1 1

4) atient-s com.ort) 89er,in0 o. bed*an& etc): -)1*NCTI.N' $' $ CIRC*L$TIN/ N*R'E 1) #*RIN/ T(E IN#*CTI.N .1 $NE'T(E'I$
1) ;urns on O! li0+t ') Assists in *ositionin0 t+e *atient

1 2 2 2 2 2 2 2 2 2 1 8 8 8 2 6 2 2 2 8

2) $1TER T(E P$TIENT I' $NE'T(ETI7E#

1) Assists in !e*ositionin0 o. t+e *atient *er anest+esiolo0ist order ') Attac+es anest+esia screen and *laces t+e *atient-s arms on t+e arm boards 2) A**lies restraints on t+e *atient 4) E5*oses t+e area .or s/in *re*aration 5) Obser,es s/in *re*aration

3) #*RIN/ .PER$TI.N
1) !emains in t+eater t+rou0+out t+e *rocedure ') <ocuses t+e O! li0+t as needed 2) Connects e7ui*ment1mac+ines 8cauter$ mac+ine& suction mac+ine: 4) ositions /ic/ buc/ets on t+e o*eratin0 side 5) !e*lenis+es and records s*on0e1sutures 6) Ensures t+e t+eater door remains close and *atient-s di0nit$ is u*+eld 7) 3aintains a sa.e en,ironment at t+e O! b$ obser,in0 t+e *rinci*les o. ase*sis and sterilit$ 8) 3onitors client-s res*onses to sur0er$) () Initiates and assists =it+ .inal s*on0e and instruments count 6) $1TER .PER$TI.N 1) >el*s remo,e and dis*ose dra*es ') Assists t+e scrub nurse& =it+ a.ter care o. instruments and e7ui*ment 2) Ensures t+at t+e t+eater is read$ .or t+e ne5t case II) ,$N$/E,ENT .1 RE'.*RCE'+ EN!IR.N,ENT and E2*IP,ENT (,RE) 1) Or0ani?es =or/ load to .acilitate timel$ *atient care ') @tili?es ade7uate and a**ro*riate resources to su**ort t+e O! team 2) Ensures .unctionalit$ o. O! resources III) (E$LT( E#*C$TI.N ((E) 1) Im*lements a**ro*riate education acti,ities to client based on needs assessment I!) LE/$L RE'P.N'I-ILITIE' (LR) 1) Ad+eres to le0al and institutional *rotocols re0ardin0 in.ormed consent) !) ET(IC. ,.R$L RE'P.N'I-ILITIE' 1) !es*ects t+e ri0+ts o. t+e O! client ') Acce*ts res*onsibilit$ and accountabilit$ .or o=n decisions and actions as an O! nurse) !I) PER'.N$L $N# PR.1E''I.N$L #E!EL.P,ENT 1) er.orms O! .unctions accordin0 to *ro.essional standards ') ossesses *ositi,e attitude to=ards learnin0 sur0ical and O! related /no=led0e and s/ills) !II) 2*$LIT3 I,PR.!E,ENT 1) artici*ates in 7ualit$ im*ro,ement acti,ities related to in.ection control and success.ul O! o*erations ') Identi.ies and re*orts ,ariances in sterilit$ and ot+er O! acti,ities !III) RE'E$RC( 1) Disseminates results o. O!-related researc+ .indin0s to clinical 0rou* and ot+er members o. t+e O! team as a**ro*riate)

6 2 2 2

2 2 2

6 2

2 2

') @tili?e .indin0s o. researc+ studies in immediate care o. t+e ne=born) I9) REC.R# ,$N$/E,ENT 1) 3aintain accurate and u*dated documentation o. t+e *atient care 9) C.,,*NIC$TI.N (Comm) 1) Establis+es ra**ort =it+ *atients& si0ni.icant ot+ers& and members o. t+e +ealt+ team ') @ses a**ro*riate in.ormation mec+anisms to .acilitate communication inside t+e O! and =it+ ot+er de*artments in t+e +os*ital) 9I) C.LL$-.R$TI.N $N# TE$,:.R; 1) Collaborates *lan o. care =it+ ot+er members o. t+e +ealt+ team T.T$L

1 2

2 1<<

Certified True and Correct:

_________________________________ _________________________________ _________________________________ Clinical Instructor (1st RLE) Clinical Instructor (2nd RLE) Clinical Instructor (3rd RLE) License Number:_________________ License Number:_______________ License Number:_______________ PRC Card !alidit" #ate: __________ PRC Card !alidit" #ate: ________ PRC Card !alidit" #ate: ________

Noted b":

$%%ro&ed b":

'$R$( ') T$*P$N+ RN+ ,N+ #P$ RN+ ,N Clinical Coordinator License Number: 0150766 !C Card " #alidit$ Date: %anuar$ 17& '015 October (& '01'

LEIL$ #) -ENIT.+ OIC- DEAN License Number: 0106758 !C Card " #alidit$ Date:

Aestern 3indanao 9tate @ni,ersit$ C.LLE/E .1 N*R'IN/ Bamboan0a Cit$ '*,,$R3 PER1.R,$NCE E!$L*$TI.N $C(IE!IN/ INTR$=.PER$TI!E C.,PETENC3 In $ccordance >it5 PRC -oard of Nursin0 ,emorandum No) <1 'eries 2<<? 'i0nature o&er Printed Name of 'tudent: $cademic 3ear /raduated: ___________________________________________ Name of Patient (Patient@s initials onl") 1st RLE: ______________________ 2nd RLE: 3
rd

______________________ ______________________

RLE:

INTR$=.PER$TI!E C.,PETENCIE' 1.R $ 'CR*- N*R'E

I) '$1E $N# 2*$LIT3 N*R'IN/ C$RE ('2C)
$) #E,.N'TR$TE' PR.PER PR.CE#*RE PRE= .PER$TI!EL3 1) er.orms sur0ical +and scrub correctl$ ') Dons sterile 0o=n ase*ticall$ 2) Dons sterile 0lo,es ase*ticall$ 4) Dra*es o*erati,e .ield correctl$ a) 3a$o 9tand b) atient 5) re*ares sur0ical instruments& s*on0es& sutures and ot+er su**lies in .unctional arran0ement 6) er.orms initial sur0ical count =it+ circulator -) *TILI7E' -$'IC ';ILL' INTR$.PER$TI!EL3 1) Obser,es *rinci*les o. strict sur0ical ase*tic tec+ni7ues =it+in t+e =or/ area at all times ') Demonstrates *ro*er +andlin0 and ser,in0 o. instruments& sutures and accessories 2) Demonstrates *ro*er *re*aration o. sutures and needles 4) Antici*ates t+e sur0eon-s needs 8su**lies and e7ui*ment: 5) 3aintains internal count o. s*on0es& needles& and instruments 6) 3aintains orderl$ sterile .ield C) I,,E#I$TE P.'T.PER$TI!E C$RE 1) er.orms sur0ical counts =it+ circulator at *ro*er inter,als ') Or0ani?es suture and dressin0s .or =ound closure 2) Assists in t+e a**lication o. *osto*erati,e sterile dressin0 4) re*ares .or terminal cleanin0 o. instruments and nondis*osable su**lies 5) Demonstrates *ro*er dis*osal o. s+ar*s& bod$ .luids and ot+er =astes II) ,$N$/E,ENT .1 RE'.*RCE'+ EN!IR.N,ENT $N# E2*IP,ENT (,RE) 1) Or0ani?es =or/load to .acilitate timel$ *atient care ') @tili?es ade7uate and a**ro*riate resources to su**ort t+e O! team 2) Ensures .unctionalit$ o. O! resources 4) 3aintains a sa.e en,ironment at t+e O! b$ obser,in0 t+e *rinci*les o. ase*sis III) (E$LT( E#*C$TI.N ((E) 1) Im*lements a**ro*riate +ealt+ education acti,ities to t+e client based on needs assessment I!) LE/$L RE'P.N'I-ILITIE' (LR) 1) Ad+eres to le0al and institutional *rotocols re0ardin0 in.ormed consent) !) ET(IC.=,.R$L RE'P.N'I-ILITIE' (E,R) 1) !es*ects t+e ri0+ts o. t+e O! client) ') Acce*ts res*onsibilit$ and accountabilit$ .or o=n decisions and actions as an O! nurse) !I) PER'.N$L $N# PR.1E''I.N$L #E!EL.P,ENT (PP#) 1) er.orms O! .unctions accordin0 to *ro.essional standards ') ossesses *ositi,e attitude to=ards learnin0 sur0ical and O! related /no=led0e and s/ills

#esire d Ratin0

1st RLE

2nd RL E

3rd RL E

$&era0e ratin0

8 8 8 3 8 8 8 2 8 3 2 8 2 8 2 2 2 2

2 2 2 2

2 2 2 2 2 2

!II) 2*$LIT3 I,PR.!E,ENT (2I) 1) artici*ates in 7ualit$ im*ro,ement acti,ities related to in.ection control and success.ul O! o*erations ') Identi.ies and re*orts ,ariances in sterilit$ and ot+er O! acti,ities !III) RE'E$RC( (R) 1) Disseminates results o. O! related .indin0s to clinical 0rou* and ot+er member o. t+e O! team as a**ro*riate ') @tili?es .indin0s o. researc+ studies o. a *ost-sur0ical *atient I9) REC.R#' ,$N$/E,ENT (R,)

2 2 2 2

1) 3aintains accurate and u*dated documentation o. *atient care 9) C.,,*NIC$TI.N (C.,,) 1) Establis+es ra**ort =it+ *atients& si0ni.icant ot+ers and members o. t+e +ealt+ team ') @ses a**ro*riate in.ormation mec+anisms to .acilitate communication inside t+e O! and =it+ ot+er de*artments in t+e +os*ital 9I) C.LL$-.R$TI.N $N# TE$,:.R; (C:) 1) Collaborates *lan o. care =it+ ot+er members o. t+e +ealt+ team T.T$L 'C.RE

2 1 2 2 1<<

Certified True and Correct:

_________________________________ _________________________________ _________________________________ Clinical Instructor ( 1st RLE) Clinical Instructor (2nd RLE) Clinical Instructor (3rd RLE) License Number:_________________ License Number:_______________ License Number:_______________ PRC Card !alidit" #ate: __________ PRC Card !alidit" #ate: ________ PRC Card !alidit" #ate: ________

Noted b":

$%%ro&ed b":

'$R$( ') T$*P$N+ RN+ ,N+ #P$ RN+ ,N Clinical Coordinator License Number: 0150766 !C Card " #alidit$ Date: %anuar$ 17& '015 October (& '01'

LEIL$ #) -ENIT.+ OIC- DEAN License Number: 0106758 !C Card " #alidit$ Date: