SCHOOL OF NURSING

General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

SUMMARY PERFORMANCE EVALUATION ACHIEVING
INTRA – OPERATIVE CARE COMPETENCY
In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Signature over Printed Name of Student: ____________________________________________

INTRA – OPERATIVE CARE COMPETENCIES Desired 1st 2nd 3rd AVERAGE

Rating RLE RLE RLE RATING
I. I. SAFE AND QUALITY NURSING CARE ( SQC)
1. Utilize the nursing process in the care of OR client.
a. Obtains comprehensive client’s information by checking complete 4
accomplishment of the preoperative checklist/ client’s chart.
b. Identifies priority needs of the client at the OR. 4
c. Provides needed nursing interventions based on identified needs. 4
d. Monitor client’s responses to surgery. 2
2. Promotes safety and comfort of the patient in the OR. 2
3. Performs the functions of the Scrub Nurse:
a. Performs surgical scrub correctly. 4
b. Wears sterile gown and gloves aseptically. 2
c. Prepares surgical instruments, sponges, sutures and other supplies in 2
functional arrangement.
d. Hands instruments, sponges, sutures and other needed materials according 2
to Surgeon’s preference.
e. Performs surgical count accurately. 2
4. Performs the functions of the Circulating Nurse.
a. Anticipates the needs of the surgical team. 4
b. Sets up the needed equipment in the OR. 2
c. Receives client for surgery/ endorses client post – operatively. 2
d. Assists in skin preparation and draping of client. 2
5. Administer medications and other health therapeutics safely. 2
II. MANAGEMENT OF RESOURCES, ENVIRONMENT, AND EQUIPMENT ( MRE )
1. Organize work load to facilitate timely patient care. 4
2. Utilizes adequate and appropriate resources to support the OR team. 2
3. Ensures functionality of OR resources. 2
4. Maintains a safe environment at the OR by observing the principles of asepsis. 2
III. HEALTH EDUCATION ( HE )
1. Implements appropriate health education activities to client based on needs
assessment. 2
IV. LEGAL RESPONSIBILITIES ( LR )
1. Adheres to a legal and institutional protocols regarding informed consent. 2
V. ETHICO – MORAL RESPONSIBILITIES ( EMR )
1. Respects the rights of the OR client. 1
2. Accepts responsibility and accountability for own decisions and actions as an OR 2
nurse.
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT ( PPD )
1. Performs OR functions according to professional standards. 4
2. Possesses positive attitude towards learning surgical and OR related knowledge
and skills. 2
VII. QUALITY IMPROVEMENT ( QI )
1. Participates in quality improvement activities related to infection control and
successful OR operations. 2
2. Identifies and reports variances in sterility and other OR activities. 2
VIII. RESEARCH ( R )
1. Disseminates results of OR related research findings to clinical group and other
members of the OR team as appropriate. 2

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 SCHOOL OF NURSING
General Luna Road, Baguio City Philippines 2600

Telefax No.: (074) 442-3071 Website: www.ubaguio.edu E-mail Address: nursing@ubaguio.edu

INTRA – OPERATIVE CARE COMPETENCIES Desired 1st 2nd 3rd AVERAGE
Rating RLE RLE RLE RATING
IX. RECORDS MANAGEMENT ( RM )
1. Maintains accurate and updated documentation of patient care. 2
X. COMMUNICATION ( Comm )
1. Establishes rapport with patients, significant others and members of the health
team. 1
2. Uses appropriate information mechanisms to facilitate communication inside
the OR and with other departments in the hospital. 1
XI. COLLABORATION AND TEAMWORK ( CTW )
1. Collaborates plan of care with other members of the health team. 2
TOTAL SCORE: 75
When graded RLE’s were performed ( Specify Academic Year and Semester )

First RLE: Academic Year_____________ 1st Sem. ____ 2nd Sem. ____ Summer ____
Clinical Instructor: Name _____________________________Signature _________________
License Number _____________________ Validity __________________

Second RLE: Academic Year_____________ 1st Sem. ____ 2nd Sem. ____ Summer ____
Clinical Instructor: Name _____________________________Signature _________________
License Number _____________________ Validity __________________

Third RLE: Academic Year_____________ 1st Sem. ____ 2nd Sem. ____ Summer ____
Clinical Instructor: Name _____________________________Signature _________________
License Number _____________________ Validity __________________

Verified True and Correct:

____________________________ License Number ______________________

Program Chair Validity_____________________________
( Signature over Printed Name )

Academic Year Graduated: _________________________________________

____________________________ License Number ______________________

Dean Validity Date ________________________
( Signature over Printed Name)

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