Ateneo de Zamboanga University

College of Nursing

Summary Performance Evaluation

Achieving Intraoperative Care Competency
In accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

OR Circulating Case (Minor)

Name of Student: HAMID, SITI ROZIANA JAMIUL

Legend: (Rating Criteria)

4 Competent (Students performs efficiently in an effective and efficient
manner)
3 Progress Acceptable (performance is usually effective and efficient
but not always)
2 Needs Improvement (progress in performance is too slow to judge
satisfactorily; task
Performance is not most of the time)
1 Progress Unacceptable (no progress in performance has been
demonstrated, and or performance
Is consistently ineffective and inefficient)

Name of Patient (Initials only) / Clinical Instructors Signature:

Case No.1 ___________________________________

Case No.2 ___________________________________
Case No.3 ___________________________________
2nd 3rd Averag
1st
INTRA-OPERATIVE CARE COMPETENCIES Cas Cas e
Case
e e Rating
I. Safe and Quality Nursing Care
1. Conducts pre-operative visit of patient for surgery
(preferably the day before/hours before surgery)
2. Receives endorsement of patient for surgery from ward
nurse.
3. Assess client for surgery.
4. Checks/validates the competencies and accuracy of the
pre-operative checklist.
5. Observes universal precautions in handling body fluids.
6. Observes surgical asepsis in her role as a circulating
nurse.
7. Transfers patient to/from the stretcher to OR table/bed.
8. Assists in proper positioning and strapping patient on the
OR table.
9. Protects the client from electrical, thermal and/chemical
injuries
- Proper placement and monitoring of cautery
pad/ground
- Appropriate blending of temperature of saline for
lavage
- Rinsing of instruments/tubing soaked in chemicals
before serving them to sterile surgical team.
10. Provides needed blankets and sheets to prevent
hypothermia/ provide privacy to the patient.
Performs various roles and functions of a scrub nurse
11. Prepares all the needed equipment and supplies for
surgery.
12. Assist the anethesiologist during the induction of
anesthesia.
13. Performs surgical skin prep to the patient.
14. Checks with the scrub nurse the completeness of
 sponges, instruments, and needles used.
15. Anticipates the needs of the sterile surgical team.
16. Ensures the intactness and functionality of all
contraptions (e.g. IVF, BT, IFC, and NGT)
17. Continuously monitors aseptic technique and patients
needs.
18. Receives specimen and labels it correctly.

19. Prepares patient for transfer to PACU.

2nd 3rd Averag
1st
INTRA-OPERATIVE CARE COMPETENCIES Cas Cas e
Case
e e Rating
20. Helps in the aftercare of all equipments and the OR as a
whole.
Performs appropriate nursing intervention to intra-
operative patients
21. Assignment: Summarizes important information about
anesthesia drugs and other common OR drugs in 4x6
index cards (to be brought every duty day as ready
reference)
22. Administers medications as ordered following all
principles in drug administration
23. Executes legal orders of the surgeon/anaesthesiologist
timely and accurately.
24. Evaluates outcomes of acre and adjust nursing
interventions as appropriate
25. Monitors patient continuously during surgery and
immediate post-operative phase
26. Presents a comprehensive case study of an assisted
surgical patient.
II. Management Of Resources, Environment, And
Equipment
27. Ensures availability, completeness and functionality,
storage of OR equipment and other resources.
28. Observes organization of work and proper budgeting of
time and resources.
29. Observes OR policies, procedures and protocol on
infection control and waste disposal.
30. Performs proper disinfection and sterilization.
31. Disposes hazardous and non-hazardous waste properly
per agency policy.
32. Conducts inventory of OR resources.
III. Health Education
33. Reinforces pre-operative health teaching to surgical
client.
34. Provides health education based on identified learning
needs of the intra-operative/post-operative patient and
his significant others.
IV. Legal Responsibilities
35. Checks and validates the completeness of the informed
consent and other legal forms.
36. Validates information documented in the endorsed chart
of client for surgery.
V. Ethico-Moral Responsibilities
37. Respect the Patients Bill of Rights.
38. Adheres to the Code of Ethics for Nurses.
VI. Personal and Professional Development
39. Accepts criticisms and recommendations.
40. Courteous and works actively with the OR staff, Clinical
Instructor, other members of the health team.
41. Prompt in reporting to RLE/duty.
42. Prompt in submitting requirements.
VII. Quality Improvement
43. Identifies deviation of practice from the standards of care
 of patient in the OR.
44. Participates in ward audit in the OR.
VIII. Research
45. Utilizes and shares relevant research findings related to
intraoperative nursing.
IX. Records Management
46. Maintains legible, complete, accurate and update
documentation of patient care in the patients chart and
other OR forms.
47. Submits timely, complete and accurate surgical slips/OR
write-ups for cases handled
X. Communication
48. Communicates therapeutically with patient and their
significant others.
49. Utilizes proper channels of communication
XI. Collaboration And Teamwork
50. Maintains a collaborative relationship with colleagues
and other members of the health team.
TOTAL SCORE: 200

Certified True and Correct:

SITI ROZIANA JAMIUL HAMID

(Signature over Printed Name)

OR CIRCULATING CASE No.1OR CIRCULATING CASE No. 2 OR CIRCULATING CASE

No. 3

____________________________ _______________________________ ____________________________

Clinical Instructor Clinical Instructor Clinical Instructor

PRC License No. _____________ PRC License No. _____________ PRC License No.
______________
Valid until: __________________ Valid until: __________________ Valid until:
___________________

Noted By: ______________________________________

BS Nursing Level Coordinator

License No. _________________

Valid Until: _________________