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AMOUNT
LEVEL
RM BOTTL HOURS RATE TIME DUE RECEIVED IVF AMOUNT
IVF ENDORSED TO
No. E No. TO RUN gtts/min STARTED TIME FROM LAST CHECK TIME INFUSED
NEXT SHIFT
SHIFT
Vitug, Joan
Chart Nurse Student Head Nurse
MEDICAL CENTER MANILA – (8th flr)
Vitug, Joan
Staff Nurse Student Head Nurse
MEDICAL CENTER MANILA – (8th flr)
MEDICATION SHEET
Nursing
Name of Drug Action Indication Contraindication Adverse Effects
Responsibilities
Generic Name:
Brand Name:
Dosage:
Frequency:
Classification:
Vitug, Joan
Medication Nurse Student Head Nurse
MEDICAL CENTER MANILA – (8th flr)
Vitug, Joan
Staff Nurse Student Head Nurse
MEDICAL CENTER MANILA – (8th flr)
GENERAL APPEARANCE
Student’s name S1 S2 S3 S4 S5 S6 S7 S8
Uniform
Apron
Cap
Shoes
Stockings/socks
Name Plate
I.D.
Grooming
Hair
No Jewelry
Fingernails
Perfume
Make-up
Legend:
(VG)-Very Good
(F)- Fair
(B)- Bad
(N/A)- Not applicable
Vitug, Joan
Student Head Nurse Clinical Instructor
Vitug, Joan
Prepared by:
Bp apparatus
Wrist Watch
Bandage scissor
Med tray
Ruler
Digital Thermometer
(Date(Shift))
Penlight
Noted by:
Clipboard
Clinical Instructor
Micropore Tape
NANDA
Tape Measure
Tourniquet
Gloves
Masks
MEDICAL CENTER MANILA – (Area)
(Date(shift))
NAME___________________________
Staff Nurse
Criteria Standard Actual
Grade Grade
I. Knowledge
a. Assessed health conditions accurately. 3
b. Identifies needs/problems of client before, during and after the procedures. 3
c. Properly intervenes t the identified nursing problems by performance of independent and 3
dependent nursing functions with minimum supervision.
d. Explains the rationale for each intervention. 3
e. Evaluates the effectiveness of nursing intervention. 3
f. Assumes the independence and responsibility over assigned task. 3
g. Needs the least supervision when doing assigned task. 3
h. Document pertinent observation and cases. 3
i. Gives appropriate health teaching instructions to clients according to needs. 3
II. Skills
a. Applies the principle of asepsis when preparing materials and equipment. 5
b. Prepares and set up needed supplies and equipment. 5
c. Uses/ operates tools for nursing intervention. 5
d. Maintains the equipment and supplies used in good working condition and in order of care. 5
e. Reports and records of data are completed and accurate. 5
III. Attitude
a. Established good interpersonal relationship with client’s family, co-worker, staff, leader, and CI 3
b. Reports to duty in complete uniform with paraphernalia and properly groomed and on time. 3
c. Has initiative, responsible and efficient. 3
d. Shows respect to himself and others. 3
e. Shows interest and enthusiasm in his work. 3
f. Submits requirement on time. 5
IV. Quizzes (20%) 20
V. Attendance 8
TOTAL 100% 100
MEDICAL CENTER MANILA – (8th flr)
ORGANIZATIONAL CHART
Clinical Instructor
Head Nurses