Semester & Academic Year:

_________________________________

Classcode/Year/Group No.:

_________________________________

Term Period:

_________________________________

Institution/ Area of Assignments: _________________________________

Dates of Clinical Duty:

_________________________________

Name of Clinical Instructor:

_________________________________

Read each items and rate accordingly using the following criteria:
4 Always
3 Most of the time
2 Sometimes
1 Never
Key Areas of
Responsibility

Management of
Environment
and Resources.

Personal and
Professional
Development

Personal and
Professional

Indicators
1. Institution/ Area of Assignment
1.1 Set-up is conducive to the learning of the students
1.2 Provides appropriate students area for ward discussion
1.3 Provides adequate number of patients for students
clinical enhancement
1.4 Presents different cases related to the concept and/or
clinical focus
1.5 Supplies and equipment are adequate and relevant
towards the enrichment of students clinical experience
2. Staff/Personnel
2.1 Demonstrates courtesy and recognition to students and
Clinical Instructor
2.2 Cooperates with the accomplishment of the set plan of
activities
2.3 Acknowledges queries from students and Clinical
Instructor
2.4 Supports the clinical focus/ concept for the duty
rotation
2.5 Provides verbal endorsement with the students and
Clinical Instructor
2.6 Allows the students in reviewing patients medical
records i.e. Chart, Kardex, etc.
2.7 Permits the students in using the hospital equipment

4 3 2 1

Development

and materials when deemed necessary

3. Clinical Instructor
3.1 Comes to clinical assignment regularly and punctually
3.2 Provides brief orientation to the students regarding
ward set-up, staff/ personnel, protocols, etc.
3.3 Answers questions with confidence sound knowledge
3.4 Demonstrates enthusiasm to teach

Personal and
Professional
Development
Personal and
Professional
Development
Quality
3.5 Provides pre and post-conferences to discuss and
Development
evaluate plan of activities and students performance
Communication
3.6 Provides clear instruction and proper endorsement
Safe and Quality
3.7 Shows effective and efficient clinical management
Care
3.8 Evaluates students objectively and fairly. Able to give
Communication constructive criticisms and words of encouragement to
stimulate students motivation and enthusiasm to learn.
3.9 Uses appropriate words during conversation. (Talks
professionally)
Quality
3.10 Maximizes the time allotted for exposure towards the
Development
enhancement of students knowledge, skills, attitude, and
social awareness.
4. Clinical experience of Students
4.1 Able to handle patient with case related to
Safe and Quality concept/clinical focus
4.2 Demonstrates assessment skills systematically and
Nursing Care
appropriately
4.3 Conducts comprehensive nursing history
Communication
4.4 Uses Effective communication techniques
4.5 Systematically performs procedures that are with the
given scenario(s)
4.6 Identifies priority nursing diagnoses based on
Safe and Quality
assessment findings.
Nursing Care
4.7 Formulates SMART (Systematic, Measurable,
Attainable, Realistic, and Time-bounded) nursing care plans
4.8 Present drug study before administering medications
Collaboration &
4.9 Participates well with group activities and discussions
Teamwork
Legal
4.10 Follows the rules and regulations set by the College
Responsibility
and the University
Comments/ Suggestions:

______________________________________________________________________________
______________________________________________________________________________

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______________________________________________________________________________
Computation:
1. Institution/ Area of Assignment
Total score multiply to 25 divided by the total number of items (5) = ______________________

2. Staff/ Personnel
Total score multiply to 25 divided by the total number of items (7) = ______________________

3. Clinical Instructor
Total score multiply to 25 divided by the total number of items (10) = _____________________

4. Clinical Experience
Total score multiply to 25 divided by the total number of items (10) = _____________________

Total
Total score multiply to 25 divided by the total number of items (32) = _____________________
Equivalent Numeric Grade = ______________________