5 4 3 2 1 0 NO

2 .6 Engages in advocacy activities to promote quality

care to clients
2 .7 Articulates the values of the school and the nursing
profession
2 .8 Demonstrates professional behavior in words and
actions consistently

Total Scores: __________________

Comments/Suggestions:

Computation: Part I=Total Score divided by 36 (number of items) x 20 (factor) x (.90)= __________
Part II=Total Score divided by 10 (number of items) x 20 (factor) x (.10)= ______________

TOTAL =

Equivalent Numeric Grade: _______________

Evaluator: Conforme:
Equivalent Numeric Grade: _______________

Clinical Instructor's Student’s Signature Date

Printed Name & Signature

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Page 3 of 3
 Criteria 5 4 3 2 1 0 NO
16. Protects clients’ rights based on the Patient’s Bill of Rights and
Obligations.
17. Collaborates with the client and the inter-professional health care
team in developing the plan of care.
18. Develops with the client an evaluation plan specifying criteria/
indicators, methods and tools.
BEGINNING NURSE'S ROLE ON MANAGEMENT AND LEADERSHIP
19. Maintains a harmonius and collegial relationships among members of the
health team for effective, efficient and safe client care.
20. Creates a safe environment of care through the use of quality assurance,
continuous quality improvement and risk and management strategies
21. Carries out strategies and actions to ensure a safe environment of care in
partnership with the health team, the client and other support staff
22. Institutes appropriate corrective actions to prevent or minimize harm
arising from adverse effects.
23. Maintains a positive practice environment.
24. Organizes own workload demonstrating time managment skills for meeting
responsibilities and achieving outcomes.
25. Modifies plan of care according to one’s judgment, skill, or
knowledge as client’s needs change.
26. Provides health education using selected using planning models to
targeted clientele (individual and family).
27. Evaluates with the client the health status/competence and/or
relationship process/expected outcomes of nurse-patient working
relationship
28. Documents clients responses/ nursing care services rendered and
processes outcomes of nurse-patient working relationship.
29. Maintains complete, accurate and up-to-date recording and reporting
system.
30. Adheres to protocol and principles of confidentiality in safekeeping
and releasing of records and other information.
BEGINNING NURSE'S ROLE ON RESEARCH
31. Reviews research literature, determining knowledge about client's
various case / disorders
32. Updates oneself with the latest trends on client's particularly nursing care
33. Identifies researchable problems in the nursing management of clients with
identified disorders
34. Utilizes findings in the research study.
35. Conducts collection and analysis of data with grp member for a CNP
(Comprehensive Nursing Process)
36. Applies ethica principles and guidelines throughout trhe phases of
making a case study and a CNP
PART II (10%) 5 4 3 2 1 0 NO
1. Establishes collaborative relationship
1.1 Maintains good interpersonal relationship with group members
Clinical Instructors, and other members of the health team
1.2 Respects the role of each member of the group, Clinical
Instructors and other members of the health team
2. Promotes professional and personal growth and development
2 .1 Identifies learning needs based on one's strengths and
weaknesses
2 .2 Decides on specific learning plan/activities to address
learning needs
2 .3 Updates self to current trends and issues in nursing
to improve competence as student nurse
2 .4 Participates in the various activities of the group
2 .5 Complies with the rules, policies and guidelines
of the school, community and other affiliation agencies

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 CENTRO ESCOLAR UNIVERSITY
School of Nursing
Manila * Makati * Malolos

CLINICAL PERFORMANCE CHECKLIST

BSN Level II, III, IV Performance Evaluation

Name of Student Score

Year/Section/Group/Number

Rate the student's performance by checking the appropriate box using the following criteria:

5 - Excellent (Carries out procedures efficiently, systematically and independently/Personality trait

is observed at all times)
4 - Very Satisfactory (Carries out procedures efficiently and systematically but requires minimal
guidance and supervision/Personality trait is observed most of the time)
3 - Satisfactory (Carries out the procedures efficiently and systematically but requires moderate
guidance and supervision/ Personality trait is observed sometimes)
2 - Fair (Carries out the procedures efficiently and systematically but requires close guidance and
supervision/Personality trait is seldom observed)
1 - Poor (Carries out the procedures inefficiently, unsystematically even under close guidance and
supervision/ Personality trait is never observed)
0 - Not Done
NO - No Opportunity

*Average mean shall be computed and multiplied by factor 20. The product shall be transmuted using
the table for 100 points. Passing cut-off score is 65%.

Criteria 5 4 3 2 1 0 NO
PART I (90%)
BEGINNING NURSE'S ROLE ON CLIENT CARE
Utilizes the nursing process in the interdisciplinary care of clients in
various cases
1. Ensures a working relationship with the client and/or support system
based on trust, respect, and shared decision making.
2. Shares pertinent information about oneself as a nurse-partner
3. Explains nature and purpose of client-partner working relationship.
4. Prepares with the client a list of objectives and expectations.
5. Carries out appropriate strategies to ensure continued participation
of the client.
6. Assesses with the client (individual and family ones health status/competence
7. Conducts a comprehensive and systematic nursing assessment within
an interdisciplinary famework.
8. Interprets data and draws inferences by specifying the nature,
magnitude and reasons for alterations, gaps, deficiencies and/or barriers.
9. States nursing diagnosis/problems and indentifying factors
associated with the existence of the condition.
10. Sets priorities among a list of conditions or problems.
11. Formulates with the client a plan of care to address the health
condition, needs, problems and issues based on the priorities.
12. Specifies goals, objectives and expected outcomes of care
maximizing client's competencies.
13. Selects appropriate interventions/strategies enhancing opportunities
for health promotion, wellness response, prevention of problems/
complications
14. Implements safe and quality interventions with the client to address
the health condition, needs, problems and issues based on the
priorities of care.
15. Performs in accordance with legal principles and code of ethics in making
personal and professional judgment

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