Zamboanga Del Sur General Hospital: Staff Nurse Performance Evaluation Sheet

ZAMBOANGA DEL SUR GENERAL HOSPITAL
STAFF NURSE PERFORMANCE EVALUATION SHEET
Name: _____________________________________________________ Date: __________________

Position: ___________________________________ Performance Period: ____________________
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 box for
each item.
Scoring guide:
5- Always 4- Most of the time 3- Sometimes
2- Seldom 1- Never N/A- Not Applicable
I. SAFE AND QUALITY NURSING CARE 1 2 3 4 5
1. Demonstrates knowledge base on the health /illness status of

individual
2. Provides sound decision making in the care of individuals / groups

considering their beliefs and values
3. Promotes safety and comfort of patients
4. Sets priorities in nursing care based on patients’ needs
5. Ensures continuity of care
6. Administers medications and other health therapeutics correctly
7. Utilizes the nursing process as framework for nursing

7.1 Performs comprehensive and systematic nursing assessment
7.2 Formulates a plan of care in collaboration with patients and

other members of the health team
7.3 Implements planned nursing care to achieve identified

outcomes
7.4 Evaluates progress toward expected outcomes
8. Responds to the urgency of the patient’s condition

II. COMMUNICATION 1 2 3 4 5
1. Establishes rapport with patients, significant others and members of

the health team
2. Identifies verbal and non-verbal cues
3. Utilizes formal and informal channels
4. Responds to needs of individuals, family, group and community
5. Uses appropriate information technology to facilitate

communication
III. COLLABORATION AND TEAMWORK 1 2 3 4 5
1. Establishes collaborative relationship with colleagues and other

members of the health team
2. Collaborates plan of care with other members of the health team
IV. HEALTH EDUCATION 1 2 3 4 5
1. Assesses the learning needs of the patient and family
2. Develops health education plan based on assessed & anticipated

needs
3. Develops learning materials for health education
4. Implements the health education plan
5. Evaluates the outcome of health education
V. LEGAL RESPONSIBILITY 1 2 3 4 5
1. Adheres to practices in accordance with the nursing law and other

relevant legislation including contracts, informed consent.
2. Adheres to organizational policies and procedures, local and
national
3. Documents care rendered to patients
VI. ETHICO-MORAL RESPONSIBILITY 1 2 3 4 5
1. Respects the rights of individual / groups
2. Accepts responsibility and accountability for own decision and

actions
3. Adheres to the national and international code of ethics for nurses
VII. PERSONAL AND PROFESSIONAL DEVELOPMENT 1 2 3 4 5
1. Identifies own learning needs
2. Pursues continuing education
3. Gets involved in professional organizations and civic activities
4. Projects a professional image of the nurse
5. Possesses positive attitude towards change and criticism
6. Performs function according to professional standards
VIII. RECORDS MANAGEMENT 1 2 3 4 5
1. Maintains accurate and updated documentation of patient

care
2. Records outcome of patient care
3. Observes legal imperatives in record keeping
IX. Management Of Resources And Environment 1 2 3 4 5

1. Organizes work load to facilitate patient care
2. Utilizes resources to support patient care
3. Ensures functioning of resources
4. Checks proper functioning of equipment
5. Maintains a safe environment
X. QUALITY IMPROVEMENT 1 2 3 4 5
1. Gathers data for quality improvement
2. Participates in nursing audits and rounds
3. Identifies and reports variances
4. Recommends solutions to identified problems
XI. RESEARCH 1 2 3 4 5
1. Gather data using different methodologies
2. Recommends actions for implementation
3. Disseminates results of research findings
4. Applies research findings in nursing practice

SUMMARY
POINTS EARNED TOTAL
 Patient Care Competencies

1. Safe and quality nursing care ________
2. Communication ________
3. Collaboration and teamwork ________
4. Health Education ________
 Empowering
5. Legal responsibility ________
6. Ethico-moral responsibility ________
7. Personal and professional development ________
 Enhancing
8. Record management ________
9. Management of resources and environment ________
 Enabling
10. Quality Improvement _________
11. Research _________
GRANDTOTAL =
FINAL RATING: __________________________

RATER:_________________________________________
REMARKS/RECOMMENDATIONS:
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________

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What are the 11 key areas of responsibility for nurses?

What are the 11 key areas of responsibility for nurses?

How is a nurse's performance evaluated?

How is a nurse's performance evaluated?

ZAMBOANGA DEL SUR GENERAL HOSPITAL

STAFF NURSE PERFORMANCE EVALUATION SHEET

Name: _____________________________________________________ Date: __________________

I. SAFE AND QUALITY NURSING CARE 1 2 3 4 5

1. Demonstrates knowledge base on the health /illness status of

2. Provides sound decision making in the care of individuals / groups

3. Promotes safety and comfort of patients

4. Sets priorities in nursing care based on patients’ needs

5. Ensures continuity of care

6. Administers medications and other health therapeutics correctly

7. Utilizes the nursing process as framework for nursing

7.2 Formulates a plan of care in collaboration with patients and

7.3 Implements planned nursing care to achieve identified

7.4 Evaluates progress toward expected outcomes

8. Responds to the urgency of the patient’s condition

1. Establishes rapport with patients, significant others and members of

2. Identifies verbal and non-verbal cues

3. Utilizes formal and informal channels

4. Responds to needs of individuals, family, group and community

5. Uses appropriate information technology to facilitate

III. COLLABORATION AND TEAMWORK 1 2 3 4 5

1. Establishes collaborative relationship with colleagues and other

2. Collaborates plan of care with other members of the health team

IV. HEALTH EDUCATION 1 2 3 4 5

1. Assesses the learning needs of the patient and family

2. Develops health education plan based on assessed & anticipated

4. Implements the health education plan

5. Evaluates the outcome of health education

1. Adheres to practices in accordance with the nursing law and other

3. Documents care rendered to patients

VI. ETHICO-MORAL RESPONSIBILITY 1 2 3 4 5

1. Respects the rights of individual / groups

2. Accepts responsibility and accountability for own decision and

3. Adheres to the national and international code of ethics for nurses

VII. PERSONAL AND PROFESSIONAL DEVELOPMENT 1 2 3 4 5

1. Identifies own learning needs

2. Pursues continuing education

3. Gets involved in professional organizations and civic activities

4. Projects a professional image of the nurse

5. Possesses positive attitude towards change and criticism

6. Performs function according to professional standards

VIII. RECORDS MANAGEMENT 1 2 3 4 5

1. Maintains accurate and updated documentation of patient

2. Records outcome of patient care

3. Observes legal imperatives in record keeping

IX. Management Of Resources And Environment 1 2 3 4 5

2. Utilizes resources to support patient care

3. Ensures functioning of resources

4. Checks proper functioning of equipment

5. Maintains a safe environment

1. Gathers data for quality improvement

2. Participates in nursing audits and rounds

3. Identifies and reports variances

4. Recommends solutions to identified problems

1. Gather data using different methodologies

Name: ___________________________________ Date: