College of Nursing

Name of Student: ________________________________ Date: ________ Score:_________

Check () the appropriate box representing how the student performed the procedure for the
graded return demonstration.
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Post Mortem Care (Score_____) pg. 146
Done
Not Done
Done
Not Done
1
10
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11
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12
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13
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14
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15
7
16
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18
10
19
Remarks: ____________________________________________________________________
Students Signature: _________________________
Clinical Instructors/ Preceptors Signature: _________________________
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Application of Restraints (Score_____) pg. 163
Done
Not Done
1
2
3
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6

Done

Not Done

7
8
9
10

Remarks: ____________________________________________________________________
Students Signature: _________________________
Clinical Instructors/ Preceptors Signature: _________________________
1

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Blood Glucose Monitoring (Score_____) pg. 214
Done
Not Done
1
2
3
4
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6
7
8
9
10

Done

Not Done

10
11
12
13
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17
18

Remarks: ____________________________________________________________________
Students Signature: _________________________
Clinical Instructors/ Preceptors Signature: _________________________
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