BACARRA MEDICAL CENTER, INC.

DR. BONIFACIA V. ALBANO MEMORIAL HOSPITAL ( PHIC ACCREDITED )

( formerly Bacarra General Hospital )
# 21 Libtong, Bacarra, Ilocos Norte Philippines
Tel No : ( 077 ) 670 3142 Fax No. : (077) 670-3150 e mail : bmc_1970@yaoo.com
STAFF NURSE PERFORMANCE EVALUATION SHEET
Name: __________________________________________________________________ Date: __________________
Position: _______________________________________________ Performance Perio: ___________________________
This evaluation aims to appraise the performance of the staff nurse in his/her assigned area at a given period of time. The 11 key
areas of responsibility of a nurse divided into 4 parts which are the core competencies for nursing practice in the Philippines is the basis for
evaluation. Put a Check ( ! mark on the appropriate bo" for each item.
#coring guide$
%& A!"a#s 4& Most of t$e time '& Sometimes
(& Se!om 1& Ne%er )/*& Not A&&!ica'!e
I( SAFE AND )UALIT* NURSIN+ CARE 1 2 3 4 5
1. Demonstrates ,no"!e-e 'ase on t$e $ea!t$ .i!!ness stat/s of ini%i/a!
2. Pro%ies so/n ecision ma,in- in t$e care of ini%i/a!s . -ro/&s consierin- t$eir 'e!iefs
an %a!/es
3. Promotes safet# an comfort of &atients
4. Sets &riorities in n/rsin- care 'ase on &atients0 nees
5. Ens/res contin/it# of care
6. Aministers meications an ot$er $ea!t$ t$era&e/tics correct!#
1( Uti!i2es t$e n/rsin- &rocess as frame"or, for n/rsin-
1(3 Performs com&re$ensi%e an s#stematic n/rsin- assessment
7.2 Form/!ates a &!an of care in co!!a'oration "it$ &atients an ot$er mem'ers of
t$e $ea!t$ team
1(4 Im&!ements &!anne n/rsin- care to ac$ie%e ientifie o/tcomes
1(5 E%a!/ates &ro-ress to"ar e6&ecte o/tcomes
8. Res&ons to t$e /r-enc# of t$e &atient0s conition
II( COMMUNICATION 3 7 4 5 8
1. Establishes rapport with patients, significant others and members of the health team
2. Identifies verbal and non-verbal cues
3. tili!es formal and informal channels
4. "esponds to needs of individuals, famil#, group and communit#
5. ses appropriate information technolog# to facilitate communication
III. COLLA9ORATION AND TEAM:OR; 1 2 3 4 5
1. Establishes collaborative relationship with colleagues and other members of the health
team
2. $ollaborates plan of care with other members of the health team
I%. HEALTH EDUCATION 1 2 3 4 5
1. &ssesses the learning needs of the patient and famil#
2. 'evelops health education plan based on assessed ( anticipated needs
3. 'evelops learning materials for health education
4. Implements the health education plan
5. Evaluates the outcome of health education
%. LE+AL RESPONSI9ILIT* 1 2 3 4 5
1. &dheres to practices in accordance with the nursing law and other relevant legislation
including contracts, informed consent.
2. &dheres to organi!ational policies and procedures, local and national
3. 'ocuments care rendered to patients
%I. ETHICO<MORAL RESPONSI9ILIT* 3 7 4 5 8
1. "espects the rights of individual ) groups
2. &ccepts responsibilit# and accountabilit# for own decision and actions
3. &dheres to the national and international code of ethics for nurses
%II. PERSONAL AND PROFESSIONAL DEVELOPMENT 3 7 4 5 8
3( Ientifies o"n !earnin- nees
7( P/rs/es contin/in- e/cation
! +ets in%o!%e in &rofessiona! or-ani2ations an ci%ic acti%ities
"! *ro+ects a professional image of the nurse
5. *ossesses positive attitude towards change and criticism
,. *erforms function according to professional standards
%III. RECORDS MANA+EMENT 3 7 4 5 8
1. -aintains accurate and updated documentation of patient care
2. "ecords outcome of patient care
3. .bserves legal imperatives in record /eeping
IX. Mana-ement Of Reso/rces An En%ironment 3 7 4 5 8
1. .rgani!es wor/ load to facilitate patient care
2. tili!es resources to support patient care
3. Ensures functioning of resources
4. $hec/s proper functioning of e0uipment
5. -aintains a safe environment
1. )UALIT* IMPROVEMENT 3 7 4 5 8
3( +at$ers ata for =/a!it# im&ro%ement
2! Partici&ates in n/rsin- a/its an ro/ns
! Ientifies an re&orts %ariances
"! Recommens so!/tions to ientifie &ro'!ems
1I. RESEARCH 3 7 4 5 8
1. 2ather data using different methodologies
2. "ecommends actions for implementation
3. 'isseminates results of research findings
4. &pplies research findings in nursing practice
SUMMAR*
POINTS EARNED TOTAL
Patient Care Com&etencies
3( #afe and +uality nursing care ,,,,,,,,
7( Communication ,,,,,,,,
4( Collaboration and teamwork ,,,,,,,,
5( -ealth .ducation ,,,,,,,,
Em&o"erin-
8( /egal responsibility ,,,,,,,,
>( .thico&moral responsibility ,,,,,,,,
1( Personal and professional development ,,,,,,,,
En$ancin-
?( 0ecord management ,,,,,,,,
@( 1anagement of resources and environment ,,,,,,,,
Ena'!in-
3A( 2uality 3mprovement ,,,,,,,,,
33( 0esearch ,,,,,,,,,
+RANDTOTAL
FINAL RATIN+: __________________________ RATER:_________________________________________
REMAR;S.RECOMMENDATIONS:_____________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
______________________________________________________________________________________________________________
APPROVED:
EMMANUEL A( DOMIN+CILB R(N(B M(A(N(
C$ief N/rsin- Officer