REPUBLIC OF THE PHILIPPINES CITY UNIVERSITY OF PASAY COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY PCGH Padre Burgos St.

, Pasay City, Metro Manila _____________________________________________________________________________ CLINICAL PERFORMANCE AND EVALUATION CHECKLIST LEADERSHIP AND MANAGEMENT (Head Nursing) Area: Medical Ward

Name: ________________________ Year___ Section___ Group Number___

Date: ________________ Rating: _______________

Instruction: Indicate the appropriate numerical rating using the label below.
Numerical Rating QUANTITATIVE DESCRIPTION

5 4 3 2 1

Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Carries out expected tasks in a very consistent manner with minimal guidance and supervision Carries out expected tasks in a consistent manner with minimal guidance and supervision Carries out expected tasks in a moderately consistent manner with frequent guidance and supervision Carries out expected tasks in a rarely consistent manner with close guidance and supervision Does not carry out expected tasks even with close guidance and supervision

PERFORMANCE
I. ESTABLISHMENT OF WORKING RELATIONSHIP 1.1 Establishes rapport with subordinates 1.2 Gains trust and confidence of subordinates 1.3 Able to mediate between subordinates and patients 1.4 Able to maintain stability under pressure II. ASSESSMENT / PLANNING 2.1 Utilizes appropriate resources for ward assessment 2.2 Utilizes different techniques in gathering data Interview Observation Records Review Reports 2.3 Gathers data on: Nursing Service History Physical Set-Up Organizational Chart Ongoing Appraisal Evaluation Ward Rules and Regulations and SOPs Channel of Communication Records and Reports 2.4 Analyzes data gathered based on scientific concepts and principles 2.5 Briefs student staff nurses on the data gathered 2.6 Identifies and prioritizes problems based on data gathered according to the urgency of

RATING

the problem, availability of resources (manpower, materials, oney/budget) III. PROBLEM SOLVING PROCESS a. Involves staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identified problems c. Analyzes the existence of the problem stating the immediate, intermediate, and root cause d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative courses of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation (effectiveness, efficiency, appropriateness, acceptability, adequacy) IV. LEADERSHIP a. Conducts a pre-conference with his / her staff to discuss the objectives and activities for the day, helps subordinates formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of tasks b. Prepares and brief subordinates on the learning objectives for the day c. Identifies patients according to the Patient Care Classification System d. Distributes patient assignment evenly e. Delegates tasks to student staff nurses f. Prepares and briefs subordinates on the daily plan of activities g. Evaluates if the objectives are met h. Identifies constraints for non-attainment of objectives and activities i. Come up with resolutions to address constraints j. Supervises his / her staff during procedures and other assigned tasks k. Schedules meetings and individual conferences l. Manages tasks using the principles of time management m. Helps staff ventilate frustrations encountered in the workplace, gives counseling as necessary n. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives o. Evaluates performances of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences p. Troubleshoots as the necessity arises q. Conducts post-conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary r. Requires incident reports as necessary, keeps the clinical instructor informed and updated s. Utilizes the existing chain of command in implementing activities

REMARKS: __________________________________________________________________________ __________________________________________________________________________

__________________ Clinical Instructor

_____________________ Student Head Nurse

REPUBLIC OF THE PHILIPPINES CITY UNIVERSITY OF PASAY COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY PCGH Padre Burgos St., Pasay City, Metro Manila _____________________________________________________________________________

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST LEADERSHIP AND MANAGEMENT (Head Nursing) Area: OB Ward Name: ________________________ Year___ Section___ Group Number___ Date: ________________ Rating: _______________

Instruction: Indicate the appropriate numerical rating using the label below.
Numerical Rating QUANTITATIVE DESCRIPTION

5 4 3 2 1

Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Carries out expected tasks in a very consistent manner with minimal guidance and supervision Carries out expected tasks in a consistent manner with minimal guidance and supervision Carries out expected tasks in a moderately consistent manner with frequent guidance and supervision Carries out expected tasks in a rarely consistent manner with close guidance and supervision Does not carry out expected tasks even with close guidance and supervision RATING

PERFORMANCE I. ESTABLISHMENT OF WORKING RELATIONSHIP 1.1 Establishes rapport with subordinates 1.2 Gains trust and confidence of subordinates 1.3 Able to mediate between subordinates and patients 1.4 Able to maintain stability under pressure II. ASSESSMENT / PLANNING 2.1 Utilizes appropriate resources for ward assessment 2.2 Utilizes different techniques in gathering data Interview Observation Records Review Reports 2.3 Gathers data on: Nursing Service History Physical Set-Up Organizational Chart Ongoing Appraisal Evaluation Ward Rules and Regulations and SOPs Channel of Communication Records and Reports 2.4 Analyzes data gathered based on scientific concepts and principles 2.5 Briefs student staff nurses on the data gathered 2.6 Identifies and prioritizes problems based on data gathered according to the urgency of

the problem, availability of resources (manpower, materials, oney/budget) III. PROBLEM SOLVING PROCESS a. Involves staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identified problems c. Analyzes the existence of the problem stating the immediate, intermediate, and root cause d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative courses of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation (effectiveness, efficiency, appropriateness, acceptability, adequacy) IV. LEADERSHIP a. Conducts a pre-conference with his / her staff to discuss the objectives and activities for the day, helps subordinates formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of tasks b. Prepares and brief subordinates on the learning objectives for the day c. Identifies patients according to the Patient Care Classification System d. Distributes patient assignment evenly e. Delegates tasks to student staff nurses f. Prepares and briefs subordinates on the daily plan of activities g. Evaluates if the objectives are met h. Identifies constraints for non-attainment of objectives and activities i. Come up with resolutions to address constraints j. Supervises his / her staff during procedures and other assigned tasks k. Schedules meetings and individual conferences l. Manages tasks using the principles of time management m. Helps staff ventilate frustrations encountered in the workplace, gives counseling as necessary n. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives o. Evaluates performances of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences p. Troubleshoots as the necessity arises q. Conducts post-conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary r. Requires incident reports as necessary, keeps the clinical instructor informed and updated s. Utilizes the existing chain of command in implementing activities REMARKS: __________________________________________________________________________ __________________________________________________________________________

__________________ Clinical Instructor

_____________________ Student Head Nurse

REPUBLIC OF THE PHILIPPINES CITY UNIVERSITY OF PASAY COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY PCGH Padre Burgos St., Pasay City, Metro Manila _____________________________________________________________________________

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST LEADERSHIP AND MANAGEMENT (Head Nursing) Area: Surgical Ward Name: ________________________ Year___ Section___ Group Number___ Date: ________________ Rating: _______________

Instruction: Indicate the appropriate numerical rating using the label below.
Numerical Rating QUANTITATIVE DESCRIPTION

5 4 3 2 1

Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Carries out expected tasks in a very consistent manner with minimal guidance and supervision Carries out expected tasks in a consistent manner with minimal guidance and supervision Carries out expected tasks in a moderately consistent manner with frequent guidance and supervision Carries out expected tasks in a rarely consistent manner with close guidance and supervision Does not carry out expected tasks even with close guidance and supervision RATING

PERFORMANCE I. ESTABLISHMENT OF WORKING RELATIONSHIP 1.1 Establishes rapport with subordinates 1.2 Gains trust and confidence of subordinates 1.3 Able to mediate between subordinates and patients 1.4 Able to maintain stability under pressure II. ASSESSMENT / PLANNING 2.1 Utilizes appropriate resources for ward assessment 2.2 Utilizes different techniques in gathering data Interview Observation Records Review Reports 2.3 Gathers data on: Nursing Service History Physical Set-Up Organizational Chart Ongoing Appraisal Evaluation Ward Rules and Regulations and SOPs Channel of Communication Records and Reports 2.4 Analyzes data gathered based on scientific concepts and principles 2.5 Briefs student staff nurses on the data gathered

2.6 Identifies and prioritizes problems based on data gathered according to the urgency of the problem, availability of resources (manpower, materials, oney/budget) III. PROBLEM SOLVING PROCESS a. Involves staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identified problems c. Analyzes the existence of the problem stating the immediate, intermediate, and root cause d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative courses of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation (effectiveness, efficiency, appropriateness, acceptability, adequacy) IV. LEADERSHIP a. Conducts a pre-conference with his / her staff to discuss the objectives and activities for the day, helps subordinates formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of tasks b. Prepares and brief subordinates on the learning objectives for the day c. Identifies patients according to the Patient Care Classification System d. Distributes patient assignment evenly e. Delegates tasks to student staff nurses f. Prepares and briefs subordinates on the daily plan of activities g. Evaluates if the objectives are met h. Identifies constraints for non-attainment of objectives and activities i. Come up with resolutions to address constraints j. Supervises his / her staff during procedures and other assigned tasks k. Schedules meetings and individual conferences l. Manages tasks using the principles of time management m. Helps staff ventilate frustrations encountered in the workplace, gives counseling as necessary n. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives o. Evaluates performances of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences p. Troubleshoots as the necessity arises q. Conducts post-conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary r. Requires incident reports as necessary, keeps the clinical instructor informed and updated s. Utilizes the existing chain of command in implementing activities REMARKS: __________________________________________________________________________ __________________________________________________________________________

__________________ Clinical Instructor

_____________________ Student Head Nurse

REPUBLIC OF THE PHILIPPINES CITY UNIVERSITY OF PASAY COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY PCGH Padre Burgos St., Pasay City, Metro Manila _____________________________________________________________________________

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST LEADERSHIP AND MANAGEMENT (Head Nursing) Area: Pediatric Ward Name: ________________________ Year___ Section___ Group Number___ Date: ________________ Rating: _______________

Instruction: Indicate the appropriate numerical rating using the label below.
Numerical Rating QUANTITATIVE DESCRIPTION

5 4 3 2 1

Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Carries out expected tasks in a very consistent manner with minimal guidance and supervision Carries out expected tasks in a consistent manner with minimal guidance and supervision Carries out expected tasks in a moderately consistent manner with frequent guidance and supervision Carries out expected tasks in a rarely consistent manner with close guidance and supervision Does not carry out expected tasks even with close guidance and supervision RATING

PERFORMANCE I. ESTABLISHMENT OF WORKING RELATIONSHIP 1.1 Establishes rapport with subordinates 1.2 Gains trust and confidence of subordinates 1.3 Able to mediate between subordinates and patients 1.4 Able to maintain stability under pressure II. ASSESSMENT / PLANNING 2.1 Utilizes appropriate resources for ward assessment 2.2 Utilizes different techniques in gathering data Interview Observation Records Review Reports 2.3 Gathers data on: Nursing Service History Physical Set-Up Organizational Chart Ongoing Appraisal Evaluation Ward Rules and Regulations and SOPs Channel of Communication Records and Reports 2.4 Analyzes data gathered based on scientific concepts and principles 2.5 Briefs student staff nurses on the data gathered 2.6 Identifies and prioritizes problems based on data gathered according to the urgency of

the problem, availability of resources (manpower, materials, oney/budget) III. PROBLEM SOLVING PROCESS a. Involves staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identified problems c. Analyzes the existence of the problem stating the immediate, intermediate, and root cause d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative courses of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation (effectiveness, efficiency, appropriateness, acceptability, adequacy) IV. LEADERSHIP a. Conducts a pre-conference with his / her staff to discuss the objectives and activities for the day, helps subordinates formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of tasks b. Prepares and brief subordinates on the learning objectives for the day c. Identifies patients according to the Patient Care Classification System d. Distributes patient assignment evenly e. Delegates tasks to student staff nurses f. Prepares and briefs subordinates on the daily plan of activities g. Evaluates if the objectives are met h. Identifies constraints for non-attainment of objectives and activities i. Come up with resolutions to address constraints j. Supervises his / her staff during procedures and other assigned tasks k. Schedules meetings and individual conferences l. Manages tasks using the principles of time management m. Helps staff ventilate frustrations encountered in the workplace, gives counseling as necessary n. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives o. Evaluates performances of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences p. Troubleshoots as the necessity arises q. Conducts post-conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary r. Requires incident reports as necessary, keeps the clinical instructor informed and updated s. Utilizes the existing chain of command in implementing activities REMARKS: __________________________________________________________________________ __________________________________________________________________________

__________________ Clinical Instructor

_____________________ Student Head Nurse

REPUBLIC OF THE PHILIPPINES CITY UNIVERSITY OF PASAY COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY PCGH Padre Burgos St., Pasay City, Metro Manila _____________________________________________________________________________

CLINICAL PERFORMANCE AND EVALUATION CHECKLIST LEADERSHIP AND MANAGEMENT (Head Nursing) Area: Out-Patient Department Name: ________________________ Year___ Section___ Group Number___ Date: ________________ Rating: _______________

Instruction: Indicate the appropriate numerical rating using the label below.
Numerical Rating QUANTITATIVE DESCRIPTION

5 4 3 2 1

Outstanding Very Satisfactory Satisfactory Needs Improvement Unsatisfactory

Carries out expected tasks in a very consistent manner with minimal guidance and supervision Carries out expected tasks in a consistent manner with minimal guidance and supervision Carries out expected tasks in a moderately consistent manner with frequent guidance and supervision Carries out expected tasks in a rarely consistent manner with close guidance and supervision Does not carry out expected tasks even with close guidance and supervision RATING

PERFORMANCE I. ESTABLISHMENT OF WORKING RELATIONSHIP 1.1 Establishes rapport with subordinates 1.2 Gains trust and confidence of subordinates 1.3 Able to mediate between subordinates and patients 1.4 Able to maintain stability under pressure II. ASSESSMENT / PLANNING 2.1 Utilizes appropriate resources for ward assessment 2.2 Utilizes different techniques in gathering data Interview Observation Records Review Reports 2.3 Gathers data on: Nursing Service History Physical Set-Up Organizational Chart Ongoing Appraisal Evaluation Ward Rules and Regulations and SOPs Channel of Communication Records and Reports 2.4 Analyzes data gathered based on scientific concepts and principles 2.5 Briefs student staff nurses on the data gathered

2.6 Identifies and prioritizes problems based on data gathered according to the urgency of the problem, availability of resources (manpower, materials, oney/budget) III. PROBLEM SOLVING PROCESS a. Involves staff, other members of the health team and administrative units in identifying problems in the unit b. Generates suggestions and recommendations for the resolution of identified problems c. Analyzes the existence of the problem stating the immediate, intermediate, and root cause d. Identifies specific and appropriate strategies to attain objectives e. Develops alternative courses of action f. Implements plan of action g. Sets criteria for evaluation using the different parameters of evaluation (effectiveness, efficiency, appropriateness, acceptability, adequacy) IV. LEADERSHIP a. Conducts a pre-conference with his / her staff to discuss the objectives and activities for the day, helps subordinates formulate strategies in accomplishing assigned tasks, address questions pertaining to accomplishment of tasks b. Prepares and brief subordinates on the learning objectives for the day c. Identifies patients according to the Patient Care Classification System d. Distributes patient assignment evenly e. Delegates tasks to student staff nurses f. Prepares and briefs subordinates on the daily plan of activities g. Evaluates if the objectives are met h. Identifies constraints for non-attainment of objectives and activities i. Come up with resolutions to address constraints j. Supervises his / her staff during procedures and other assigned tasks k. Schedules meetings and individual conferences l. Manages tasks using the principles of time management m. Helps staff ventilate frustrations encountered in the workplace, gives counseling as necessary n. Coordinates and collaborates with other members of the health team and other administrative units in the attainment of objectives o. Evaluates performances of staff and the unit as a whole through the use of reports, records, observations, interviews, and conferences p. Troubleshoots as the necessity arises q. Conducts post-conference at the end of the shift, resolves issues and concerns and conducts debriefing as necessary r. Requires incident reports as necessary, keeps the clinical instructor informed and updated s. Utilizes the existing chain of command in implementing activities REMARKS: __________________________________________________________________________ __________________________________________________________________________

__________________ Clinical Instructor

_____________________ Student Head Nurse