FAR EASTERN UNIVERSITY

Institute of Nursing

CLINICAL PERFORMANCE EVALUATION TOOL

LABOR AND DELIVERY ROOM

NAME: _______________________________________________________________ SCORE: _______________________

SECTION / GROUP NO: _________________ SHIFT: ________________ FACULTY: ____________________________
AGENCY: ________________________________________ INCLUSIVE DATES: ___________________________________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION

3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.

I. SAFE AND QUALITY NURSING CARE (SQC) RATING REMARKS

1. Utilizes the nursing process in the care of pregnant women in labor.
0 1 2 3
a. Assesses pregnant women in labor
b. Identifies priority needs of patients in labor 0 1 2 3
c. Provides nursing interventions based on identified needs 0 1 2 3
d. Monitors the progress of labor 0 1 2 3
2. Provides safety and comfort of patients in the Delivery Room
2.1 Transfers patient from stretcher to delivery table 0 1 2 3
2.2 Positions the patient in delivery room table 0 1 2 3
2.3 Drapes the patient on labor 0 1 2 3
3. Performs/Assists in labor and delivery
3.1 Performs sterile hand washing technique correctly 0 1 2 3
3.2 Prepares/arranges the DR instruments and articles needed 0 1 2 3
3.3 Handles/assists in the delivery of newborn 0 1 2 3
3.4 Announces the time of birth and baby’s gender 0 1 2 3
3.5 Clamps the cord 0 1 2 3
3.6 Milk and cuts the cord 0 1 2 3
3.7 Performs immediate newborn care 0 1 2 3
4. Performs/Assists in the delivery of placenta 0 1 2 3
5. Assists in perineal suturing 0 1 2 3
6. Does after care of the mother and equipment 0 1 2 3

/revised as of June 2015/

Name: ____________________________________ Labor and Delivery Page 2

II. MANAGEMENT OF RESOURCE AND ENVIRONMENT RATING REMARKS

1. Maximize use of available resources 0 1 2 3
2. Maintain safe environment 0 1 2 3
3. Perform after care of equipment 0 1 2 3
III. HEALTH EDUCATION
1. Provide clear instructions in assisting the mother in bearing down 0 1 2 3
2. After labor, initial health teachings about breastfeeding like cleaning the
0 1 2 3
nipples and observing the sucking & swallowing reflex of the newborn
IV. LEGAL RESPONSIBILITIES (LR)
1. Adheres to legal and institutional protocols regarding Informed Consent 0 1 2 3
2. Proper identification of neonate 0 1 2 3
V. ETHICO - MORAL RESPONSIBILITIES (EMR)
1. Respects the rights of the patient 0 1 2 3
2. Accepts responsibility and accountability for own decisions and actions
0 1 2 3
as a DR student
3. Projects a positive image of the profession 0 1 2 3
VI. PERSONAL DEVELOPMENT ( PD)
1. Observes punctuality 0 1 2 3
2. Observes grooming and proper decorum 0 1 2 3
VII. QUALITY IMPROVEMENT (QI)
1. Participates in quality improvement activities related to infection control
0 1 2 3
and successful deliveries
VIII. RESEARCH
1. Utilize EBN research finding applicable in labor and delivery 0 1 2 3
IX. RECORD MANAGEMENT (RM)
1. Presents comprehensive, neat, legibly written documents 0 1 2 3
2. Obtain and maintains accurate and updated documentation of patient care 0 1 2 3
3. Documents/monitors proper record storage, retention and disposal 0 1 2 3
X. COMMUNICATION
1. Establishes rapport with patient, significant others and members of the
0 1 2 3
health team
2. Update health team members on patient’s condition 0 1 2 3
XI. COLLABORATION AND TEAMWORK ( CTW)
1. Works efficiently as part of the DR team 0 1 2 3
2. Assists and observes all procedures 0 1 2 3
3. Refers patient to other health team members whenever necessary 0 1 2 3
4. Provides comprehensive endorsement for continuity of care 0 1 2 3

Total Score ÷ 90 X 100 = _________________

______________________________________ _________________________________________
Signature of Student Signature of Faculty
/revised as of June 2015/