CAPITOL MEDICAL CENTER COLLEGES

College of Nursing
#4 Sto. Domingo Avenue., Quezon City

RELATED LEARNING EXPERIENCE

Leadership and Management
(Head Nursing)

Name________________________________________Section/Group___________________
Clinical Area__________________________ Duration of Exposure______________________

INDIVIDUAL NURSING CARE PLAN

5 – excellent 4 – very satisfactory 3 – satisfactory

2 – needs improvement 1 – poor

CRITERIA 5 4 3 2 1
Assessment/Cues
Diagnosis
Background Knowledge
Statement of Goals
Statement of Objectives
Interventions
Rationale
Evaluation
Submitted on time
Neatness
TOTAL

Total Score
-------------- X 100 =
50

Evaluated by: Conforme by:

_______________________________ ____________________________
Student Head Nurse Student Staff Nurse

Noted by:

______________________________________
Clinical Instructor
 CAPITOL MEDICAL CENTER COLLEGES
College of Nursing
#4 Sto. Domingo Avenue., Quezon City

RELATED LEARNING EXPERIENCE

Leadership and Management
(Head Nursing)

Name________________________________________Section/Group___________________
Clinical Area__________________________ Duration of Exposure______________________

DAILY TASK SHEET (Charting)

5 – excellent 4 – very satisfactory 3 – satisfactory

2 – needs improvement 1 – poor

CRITERIA 5 4 3 2 1
Subjective Data
Objective Data
Interventions
Evaluation
Neatness
Promptness in submission of written output
TOTAL

Total Score
-------------- X 100 =
30

Evaluated by: Conforme by:

_______________________________ ____________________________
Student Head Nurse Student Staff Nurse

Noted by:

______________________________________
Clinical Instructor
 CAPITOL MEDICAL CENTER COLLEGES
College of Nursing
#4 Sto. Domingo Avenue., Quezon City

RELATED LEARNING EXPERIENCE

Leadership and Management
(Head Nursing)

Name________________________________________Section/Group___________________
Clinical Area__________________________ Duration of Exposure______________________

DRUG ANALYSIS

5 – excellent 4 – very satisfactory 3 – satisfactory

2 – needs improvement 1 – poor

CRITERIA 5 4 3 2 1
Generic Name/Brand Name
Indication & Dosage
Drug Actions
Adverse Reactions
Contraindications
Nursing Considerations
Check the Expiration Date of the Drug Before
Preparation
States Why the Drug is Given to the Patient
States the 10 R’s in Drug Administration
TOTAL

Total Score
-------------- X 100 =
45

Evaluated by: Conforme by:

_______________________________ ____________________________
Student Head Nurse Student Staff Nurse

Noted by:

______________________________________
Clinical Instructor