ST.

THERESE - MTC COLLEGES

College of Nursing
La Fiesta Site, M.H. delPilar St., Molo, Iloilo City

SUMMARY PERFORMANCE EVALUATION ACHIEVING INTRA-OPERATIVE CARE COMPETENCY In Accordance with PRC Board of Nursing Memorandum No. 1 Series of 2009

Signature over Printed Name of Student: ___________________________________________________

INTRA-OPERATIVE CARE COMPETENCIES RLE Exposure No. 1 2 3 SCRUB CIRCULATING

DESIRED RATING

ACTUAL RATING

I. SAFE AND QUALITY NURSING CARE (SQC) 1. Utilizes the nursing process in the care of OR client Obtains comprehensive clients information by checking complete accomplishment of the preoperative checklist/clients chart Identifies priority needs of the client in the Operating Room Provide needed nursing interventions based on identified needs Monitors clients response to surgery 2. Provides safety and comfort of patient inside the OR 3. Performs the function of the scrub nurse Performs surgical scrub correctly Wears sterile gowns and gloves aseptically Prepares surgical instruments, sponges, sutures, and other supplies in functional arrangement Hands instruments, sponges, sutures, and other needed materials according to the surgeon's preference Performs surgical count accurately 4. Performs the function of circulating nurse Anticipates the needs of the surgical team Set up the OR and needed equipment Receives client for surgery/endorses client post operatively Assist in skin preparation and draping of client 5. Administers medication and other health therapeutic safely II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE) 1. Organizes work load to facilitate timely patient care 2. Utilizes adequate and appropriate resources to support the OR team 3. Ensures functionality of OR resources 4. Maintain a safe environment at the OR by observing the principles of asepsis III. HEALTH EDUCATION (HE) 1. Implements appropriate health education activities to client based on needs assessment IV. LEGAL RESPONSIBILITIES (LR) 1. Adheres to legal and institutional protocols regarding informed consent

4 4 2 2 4 2 2 2 2 2 2 2 2 2 4 2 2 2

V. ETHICO-MORAL RESPONSIBILITIES (EMR) 1. Respects the right of the client 2. Accepts responsibility and accountability for own decisions and actions as an OR nurse VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD) 1. Performs OR functions according to professional standard 2. Possesses positive attitude towards learning surgical and OR - related knowledge and skills VII. QUALITY IMPROVEMENT (QI) 1. Collaborates plan of care with other members of the health team 2. Identifies and reports variances in sterility and other OR activities VIII. RESEARCH ( R ) 1. Disseminates results of OR-related research findings to clinical group and other members of OR team IX. RECORDS MANAGEMENT (RM) 1. Maintain accurate and updated documentation of patient care X. COMMUNICATION (COM) 1. Establishes rapport with patient's SO and members of health team 2. Uses appropriate information mechanisms to facilitate communication inside the OR and with other departments in the hospital XI. COLLABORATION AND TEAMWORK (CTW) 1. Collaborates plan of care with other members of the health team TOTAL SCORE

2 2

4 2

2 2 2

2 1 2

2 75

PERCENTAGE: __________ Graded RLE: Academic Year __________________ 1stSem_____ 2ndSem_____ Summer_____

Certified True and Correct:

(Printed Name and Signature)

Name: PRC No.: Valid Until:

_________________________________ Clinical Instructor _________________________________ _________________________________

Name: PRC No.: Valid Until:

_________________________________ Clinical Coordinator _________________________________ _________________________________

Name: PRC No.: Valid Until:

_________________________________ Dean _________________________________ _________________________________