TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

DATE INTRAVENOUS FLUID FLOW SPECIAL ENDORSEMENT

DATE SIDE DRIP/BLOOD FLOW

TRANSFUSION

Room: ___________ Case Number.: ______________ Date & Time of Admission: ________________
Patient’s Name: _______________________________ Attending Physician: ______________________
Age & Sex: _________ Birthday: ____________ Final Diagnosis: _________________________
Chief Complaint: _____________________________ _______________________________________
Admitting Diagnosis: __________________________ Date & Time of Discharge: _________________
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

K A R D E X
LOC AFFECT ACTIVITIES MONITORING
___ Conscious ___ Calm ___ may ambulate ___ V/S _____________________
___ Confused ___ Depressed ___ may sit at bedside ___ NVS ____________________
___ Lethargic ___ Anxious ___ CBR with BRPs ___ BP ______________________
___ Stuporous ___ Restless ___ CBR without BPRs ___ PR/CR __________________
___ Comatose Others: Others: ___ RR _____________________
______________ _________________ ___ Temp. ___________________
___ I & O ___________________
___ Wt. _____________________
Others: _____________________

DIET CONTRAPTIONS ALLERGIES

(FOOD/MEDICATION)
___ Full ___ NGT ___ Traction
___ Soft ___ IFC ___ Drain
___ Liquid ___ CTT ___ Cast
___ NPO ___ Colostomy
Others: ___ O2
___________ Others:
__________________________________
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

SURGICAL SLIP
Name of Hospital/Agency: ______________________________________________________
Date: ________________ Shift: _________________

Name of Student: _______________________________________________________________

Name of Patient:
______________________________________________________________________________ First
Name Middle Name Last Name
Case Number: _____________________ Time Started: __________________
Age: ______ Sex: _________

1st Surgeon: ___________________________________________________________________

2nd Surgeon: __________________________________________________________________
Anesthesiologist: _______________________________________________________________

Type of Anesthesia: _____________________________________________________________

Pre-Op Diagnosis: ______________________________________________________________
Post-Op Diagnosis: _____________________________________________________________
Surgical Procedure Performed: ____________________________________________________
______________________________________________________________________________

Student Nurse
Instrument Nurse: ______________________________________________________________
Circulating Nurse: ______________________________________________________________

OR Nurse On Duty
______________________________________________________________________________
First Name Middle Name Last Name
License Number: ____________________ OR Nurse Signature: ___________________

Clinical Instructor
Name: ________________________________________________________________________
License Number: ____________________ Signature: _________________________

Form No.: TSU-COS-SF-05 Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 6
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

ATTENDANCE LOGSHEET
Year and Section: _______ Group No. _____
Area / Ward: ________________ Rotation Period: ________________________

Date
No. Name of Students
Time- Signatur Signatur Signatur Signatur
Time-in Signature Time-in Signature Time-in Time-in Time-in Time-in Signature Time-in Signature
in e e e e
1
2
3
4
5
6
7
8
9
10

Clinical Instructor:
____________________________
(Signature Over Printed Name)

Chairperson:
___________________________
(Signature Over Printed Name)

Form No.: TSU-COS-SF-12 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

DAILY PHYSICAL EXAMINATION REPORT

Name of Patient: __________________________ Age: ________Date of Birth: ______________
Medical Diagnosis: _______________________ Nursing Diagnosis: ________________________
Assessed by: _____________________ Date of Assessment: ______________ Time: _____

Assessment
Area N AbN Description of Findings & Interpretation
General Appearance
Posture
Hygiene/Grooming
Nutrition/Diet
Body Size/Habitus
Height: ________
Weight: _______
Supply appropriate data:
 IBW: ___________
 BMI: ___________
 IRS: ____________
Behavior
LOC
Vital Signs
Temperature: _______
Pulse Rate: _________
Rhythm: __________
Respiration Rate: ________
Rhythm: ___________
Blood Pressure: __________
Skin
Color
Temperature
Turgor
Texture
Integrity
Unusual Marks
Rashes, Lesions
Pressure sore: Yes ___ No
Site: ___________________
Edema: Yes ____ No ____
Site: _______
Type: _____
Size/Degree: _____
Hair
Texture
Thickness
Color & Distribution
Hygiene Status
Nails
Color & Shape
Hygiene Status
Presence of Clubbing
Head
Shape & Symmetry
Unusual swelling
Cranial bruit

Form No.: TSU-

Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6
COS-SF-
 Assessmen
Area t Description of Findings & Interpretation
N AbN
Eyes
Size, placement &
alignment
Cornea
Pupils
 Size (mm)
PERRLA
Visual Acuity
Orbital Bruit
Other Findings:
________________
Ear
Location/Alignment
Pinna, Cannals, Drums
Hygiene
Discharge and Odor
Hearing Acuity
Tinnitus
Vertigo/Dizziness
Other Findings: ______
Nose
Shape
Symmetry
Patency
Mucosal Integrity
Epistaxis
Sinuses
Other Findings: ______
Lips
Integrity
Symmetry
Color
Other Findings: _
Mouth
Hygiene
Number & Condition of Teeth
Gums
Mucosal Integrity
Tongue
Tonsils
Palate
Parotid Gland
Hoarseness
Other Findings:
Neck
Carotid Bruit
Neck Veins
Thyroid
Trachea
Rigidity/Tenderness
Mass/Bruises
Other Findings:_______
Chest and Lungs
Shape & Symmetry
 Nipple & Areola
 Mass/Lump
 Others:__________

Effectivity Date: June 22,

Form No.: TSU-COS-SF- Revision No.: 00 Page 2 of 6
2016
 Assessment
Area N AbN Description of Findings & Interpretation
Chest and Lungs
Breathing
 Spontaneity
 With Ventilator
 With Tracheostomy
 Rhythm
 Depth
 Effort
Use of Accessory Muscles
a. Intercostals
b. Abdominal
c. Sternocleidomastoid
d. Trapezius
Cough
Sputum Production: Yes __ No: __
 Amount: _____________
 Consistency: __________
 Color: _______________
 Odor: _______________
Chest X-ray Result
Breath Sound (Specify)
a. Bronchial
b. Crackles
c. Rhonci
d. Wheezes
e. Stridor
f. Crepitus
CTT
Location: __________
Suction: ___________
Water Level: _______
Quality of Drainage: ___________
ABG
Other Findings: ________________
Heart
History
With Palpitation
Dyspnea
Rhythm
Point of Maximal Impulsec(PMI)
(PMI is felt at 5th ICS at apex
of heart) Specify:
a. Heaves
b. Clicks
c. Splitting
d. Thrills
e. Callops
f. Muffles
Presence of Heart Sounds
a. S1
b. S2
c. S3
d. S4
Murmurs
a. Systolic
b. Diastolic

Form No.: TSU-COS- Revision No.: Effectivity Date: June 22,

Page 3 of 6
SF- 00 2016

Assessment
Area Description of Findings & Interpretation
Back
 Spine
 Paralumbar
Other Findings: ________________
Genitalia
Symmetry
Presence of Tenderness
Urethral Discharge
Bleeding
Pelvic Pain
LMP: ________________
With Dysuria
With Flank Pain
Nocturia
History of Urinary Stone
History of Impotence
With Urinary Catheter
Urinalysis Finding: _____________
Peritoneal Dialysis (PD)
a. Date Started
b. Incorporation
c. Cycle Exchange
Amount: _______________
Dwell Time: ____________
Drainage Time: __________
d. PD Return
Color: __________
Flow: __________
Hemodialysis
Frequency: ________________
Last HD: __________________
Amount of Fluid Removed: _____
Next HD: __________________
Place: ____________________
Form No.: TSU-COS- Revision No.: Effectivity Date: June 22,
Page 4 of 6
SF- 00 2016

Assessment
Area N AbN Description of Findings & Interpretation
Rectal Examination
Anal Inspection
With Hemorrhoids: Yes:__ No:__
Location: ______________
Characteristics: _________
Mass
Last Bowel Movement: _________
Characteristic of Stool: __________
Other Findings:
________________
Nodes
Lymphadenopathy
Location
a. Cervical R ___ L ___
b. Axillary
c. Inguinal R ___ L ___
Others ______________
Extremity
Texture
Capillary Refill
Peripheral Pulse (both sides)
 Carotid
 Radial
 Ulna
 Brachial
  Femoral
 Posterior Tibial
 Dorsalis Pedis
 Popliteal
Clubbing of Fingers
Varicosities
Thrombophlebitis
Cyanosis
Joints
 Erythema
 Tenderness
 Deformity
 Swelling
Muscles
 Bulk
 Tone
 Tenderness
Ulcerations
Edema
Other Findings:
________________

Form No.: TSU-COS- Revision No.: Effectivity Date: June 22,

Page 5 of 6
SF- 00 2016

Assessment
Area N AbN Description of Findings & Interpretation
Hematopoietic
Easy Bruisability
Excessive Bleeding
Anticoagulants
Bleeding Profile
Anemia
Hematology Report
Other Findings: ________________
Neurology
Assessment of Cranial Nerves
 CN I (Olfactory)
 CN II (Optic)
 CN III (Oculomotor)
 CN IV (Trochlear)
 CN V (Trigeminal)
 CN VI (Abducens)
 CN VII (Facial)
 CN VIII (Vestibulocochlear)
 CN IX (Glossopharyngeal)
 CN X (Vagus)
 CN XI (Spinal Accessory)
 CN XII (Hypoglossal)
Motor and Posture
Sensory Perception
 Reflexes
a. Indicate Type of Reflex______
________________________
b. Pathologic Reflex: Yes__
No__
Other Findings:
_________________
Patient’s ADL
a. Bathing
b. Dressing
c. Elimination
d. Mobility and Movement

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 6 of 6

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

CLINICAL CASE ANALYSIS

Name of Patient Age: Gender:

Address Date Admitted:
Diagnosis

NURSING HISTORY:

PATHOPHYSIOLOGY:
 DIAGNOSTIC PROCEDURES:

MEDICAL MANAGEMENT:

Name of Student:
Date Submitted: C.I.’s Signature

Form No.: TSU-COS-SF-04 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

CRITERIA STANDARDS PERFECT SCORE GROUP NUMBER

         
Systematic and logical presentation of
Organization 10
report.          
Correctness of processing and
15
Content interpretation of data.          
Clear and unambiguous presentation. 15          
Conciseness (e.g. Presentation of
15
essential information in relation to report.)          
Use of visual aids facilitated
5
Visual aids comprehension of presentation.          
Neat and proportional visuals. 5          
 Report was presented within the alotted
Use of time 10
time for the group.          
Mastery and Ability of all presentors to answer relevant
20
tact questions.          
Dispassionate reactions to clarifications
5
and criticisms.          
  TOTAL 100          
EVALUATION SHEET FOR CASE PRESENTATION & DEFENSE

Name of Rater: ________________________________

Signature Over Printed Name

Date: _______________

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

INVENTORY OF BASIC & INTERMMEDIATE NURSING SKILLS / PROCEDURES

PERFORMED IN THE CLINICAL WARD
(For BSN Level 3 & 4)

Name: _______________________________ Section: _____ Semester: _____ SY:

______

Date Performed with C.I.’s Signature

1st Rotation 2nd Rotation 3rd Rotation 4th Rotation 5th Rotation 6th Rotation
Skills / Procedures
Dat C.I. Date C.I. Date C.I. Date C.I. Date C.I. Dat C.I.
e e
Assessing Body Temperature
Assessing Peripheral Pulse
Assessing an Apical Pulse
Assessing an Apical Radial
Pulse
Assessing Respirations
Assessing Blood Pressure
Handwashing
Establishing & Maintaining a
Sterile Field
Donning & Removing Sterile
Gloves (Open Method)
Donning & Removing Sterile
Gloves (Closed Method)
Bed Bath
Shampooing Hair of Client
Confined to Bed
Providing Perineal-Genital Care
Brushing & Flossing Teeth
Providing Special Oral Care
Changing / Preparing an
Unoccupied Bed
Preparing a Surgical Bed
Changing / Preparing an
Occupied Bed
Collecting Urine Specimen
Collecting Specimen from IFC
or Drainage Bag
Administering Oral Medications
Preparing Medications from
Ampule
Preparing Medications from
Vials
Mixing Medications Using One
syringe
Administering an Intradermal
Injection
Administering a Subcutaneous
Injection
Administering an Intramuscular
Injection
Adding Medications to
Intravenous Containers
Administering Intravenous
Medication Using IV Push
Administering Ophthalmic
Medications
Administering Otic Instillations
Administering Vaginal
Instillations
Moving Client Up in Bed
Turning Client to Lateral or
Prone Position in Bed
Logrolling a Client 

Form No.: TSU-COS -SF-01 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 3

Date Performed with C.I.’s Signature

Skills / Procedures 1st 2nd 3rd 4th 5th 6th
Rotation Rotation Rotation Rotation Rotation Rotation
Dat C.I. Date C.I. Date C.I. Date C.I. Date C.I. Dat C.I.
e e
Assisting Client to Sit on Side of
Bed (Dangling)
Transferring Client Between
Bed and Chair
Transferring Between Bed and
Stretcher
Assisting Client to Ambulate
Providing a Back Massage
Administering an Enema
Performing Urinary
Catheterization
Performing Bladder Irrigation
Administering Oxygen by
Cannula, Face Mask
Starting an Intravenous Infusion
Monitoring an Intravenous
Infusion
Changing an Intravenous
Container, Tubing
Discontinuing an Intravenous
 Infusion
Changing an Intravenous
Catheter to an Intermittent
Infusion Lock / Heplock
Nebulization
Obtaining Capillary Blood
Specimen and Measuring Blood
Glucose
Obtaining Wound Drainage
Specimen
Irrigating a Wound
Pre-Op Care: Teaching Moving,
Leg Exercises, Deep Breathing
& Coughing Purposes
Managing Gastrointestinal
Suction
Cleansing Sutured Wound and
Applying Sterile Dressing
Inserting Nasogastric Tube
Removing Nasogastric Tube
Administering Tube Feeding
Performing Gastrostomy or
Jejunostomy Feeding
Changing Bowel Diversion
Ostomy Appliance
Providing Tracheostomy Care
Suctioning Oropharyngeal and
Nasopharyngeal Cavities
Suctioning a Tracheostomy or
Endotracheal Tube
Initiating, Maintaining and
Terminating a Blood
Transfusion
OR Gloving and Gowning
Instrumentation Preparation
(Minor & Major)
Assisting During Anesthesia
Induction
Assisting in Lumbar Puncture
Administration of TPN and PPN
Care of Chest Tube Drainage
ECG Monitoring
Others: (Specify)

Legend: To be placed inside the date box.

O: Observed
P: Performed
Form No.: TSU-COS-SF-01 Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 3

TO BE ACCOMPLISHED BY THE STUDENT:

Inclusive Dates of Area of Clinical Clinical Instructor’s

Clinical Instructor (C.I.)
Rotation Experience Signature

***This document must be submitted to Level Coordinator during Clearance Signing.

Date Submitted: ______________________________

Evaluated by: ______________________________

Clinical Instructor

Noted by:

Prof. Lorna C. Gamis RN, MAN

CHAIRPERSON, DEPARTMENT OF NURSING

Prof. Mary Jane N. Rigor, RN, MSN

DEAN, COLLEGE OF SCIENCE

Form No.: TSU-COS-SF-01 Revision No.: 00 Effectivity Date: June 22, 2016 Page 3 of 3

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

INVENTORY OF BASIC NURSING SKILLS / PROCEDURES

PERFORMED IN THE CLINICAL WARD
(For BSN Level 2)

Name: _________________________________ Section: _____ Semester: _____ SY:______

Date Performed with C.I.’s Signature

Skills / Procedures 1st Rotation 2nd Rotation 3rd Rotation 4th Rotation 5th Rotation 6th Rotation
Date C.I. Date C.I. Date C.I. Date C.I. Date C.I. Date C.I.
Assessing Body Temperature
Assessing Peripheral Pulse
Assessing an Apical Pulse
Assessing an Apical Radial
Pulse
Assessing Respirations
Assessing Blood Pressure
Handwashing
Establishing & Maintaining a
Sterile Field
Donning & Removing Sterile
Gloves (Open Method)
Donning & Removing Sterile
Gloves (Closed Method)
Bed Bath
Shampooing Hair of Client
Confined to Bed
Providing Perineal-Genital Care
Brushing & Flossing Teeth
Providing Special Oral Care
Changing / Preparing an
Unoccupied Bed
Preparing a Surgical Bed
Changing / Preparing an
Occupied Bed
Collecting Urine Specimen
Collecting Specimen from IFC or
Drainage Bag
Administering Oral Medications
Preparing Medications from
Ampule
Preparing Medications from
Vials
Mixing Medications Using One
syringe
Administering an Intradermal
Injection
Administering a Subcutaneous
Injection
Administering an Intramuscular
Injection
Adding Medications to
Intravenous Containers
Administering Intravenous
Medication Using IV Push
Administering Ophthalmic
Medications
Administering Otic Instillations
Administering Vaginal
Instillations
Moving Client Up in Bed
Turning Client to Lateral or
Prone Position in Bed
Logrolling a Client
Assisting Client to Sit on Side of
Bed (Dangling)
Transferring Client Between Bed
and Chair

Form No.: TSU-COS-SF-02 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 3

Date Performed with C.I.’s Signature

Skills / Procedures 1st Rotation 2nd Rotation 3rd Rotation 4th Rotation 5th Rotation 6th Rotation
Date C.I. Date C.I. Date C.I. Date C.I. Date C.I. Date C.I.
Transferring Between Bed and
Stretcher
Assisting Client to Ambulate
Providing a Back Massage
Administering an Enema
Performing Urinary
Catheterization
Performing Bladder Irrigation
Administering Oxygen by
Cannula, Face Mask
Starting an Intravenous Infusion
Monitoring an Intravenous
Infusion
Changing an Intravenous
Container, Tubing
Discontinuing an Intravenous
Infusion
Changing an Intravenous
 Catheter to an Intermittent
Infusion Lock / Heplock
Nebulization

TO BE ACCOMPLISHED BY THE STUDENT:

Inclusive Dates of Area of Clinical Clinical Instructor’s

Clinical Instructor (C.I.)
Rotation Experience Signature

***This document must be submitted to Level Coordinator during Clearance Signing.

Date Submitted: ______________________________

Evaluated by: ______________________________

Clinical Instructor

Noted by:

Prof. Lorna C. Gamis RN, MAN

CHAIRPERSON, DEPARTMENT OF NURSING

Prof. Mary Jane N. Rigor, RN, MSN

DEAN, COLLEGE OF SCIENCE

Form No.: TSU-COS-SF- Revision No.:

Effectivity Date: June 22, 2016 Page 1 of 3
02 00

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

LABOR ROOM / DELIVERY ROOM & NURSERY SLIP

Name of Hospital / Agency: ____________________________________________________________

Shift:
Date: __________________________ ____________________

Name of Student: __________________________________________________________________

Name of Patient:
__________________________________________________________________________________
 Middle Last
First Name Name Name

Time Started:
Case Number: ____________________________ __________________________
Age: ____________ Sex: (For the Newborn) ____________

Procedure Performed:
__________________________________________________________________________________

LR/DR Nurse On Duty / Nursery Nurse on Duty

__________________________________________________________________________________
First Name Middle Name Last Name
License Number: ______________________ OR Nurse DR Nurse
Signature: ____________________________ Signature :

Clinical Instructor
Name: ___________________________________________________________________________
License Number: __________________________ Signature: ___________________

Form No.: TSU-COS-SF- Revision No.:

Effectivity Date: June 22, 2016 Page 1 of 1
06 00

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

________________________
Date

Sir / Madam:

This is to inform you that Mr. / Miss _________________________________ of BSN ________

had a computed Midterm Grade of _____ in the Subject / Concept _______________________.

Please be informed that the College’s Retention Policy is strictly enforced to sustain and uplift
the quality of Nursing Education. It would be greatly appreciated if you can find time to see the
herein signed Instructor of the subject/concept to discuss with the details of the above-mentioned
Midterm Grade and the academic performance of your son/daughter during the Midterms period.

Thank you.

Respectfully yours,

_______________________________
Signature Above Printed Name of Instructor

NOTED:

Prof. Lorna C. Gamis, RN, MAN

Chairperson, Department of Nursing

Prof. Mary Jane N. Rigor, RN, MSN

Dean, College of Science

=====================================================================
===========

ACKNOWLEDGEMENT

This is to certify that I have read the notice and was made aware of my son’s / daughter’s
computed Midterm Grade on the above-mentioned Subject / Concept.

Student’s Name: ________________________________________________________

____________________________________________ ___________________
Parent’s/Guardian’s Signature Above Printed Name Date

NOTE:
This part should be returned to the concerned Instructor.

Form No.: TSU-COS-SF-07 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

Name Area
Inclusive dates
Year Level RLE Group
of Rotation
PARAPHERNALIA CHECKLIST
Items / Date
Sphygmomanometer
Stethoscope
Small ruler
Penlight
Thermometer (Digital) – 2
Medicine cup
Medicine tray
Surgical gloves – clean
Surgical gloves – sterile
Tongue depressor
Tape measure
Kidney basin
Mask
Syringes (1cc, 3cc, 5cc, 10cc)
Logbook
Pencil
Eraser
Sharpener
Ballpens (blue/black, red, green)
Dry cotton balls
Wet cotton balls(with alcohol)
Alcohol
Betadine
Bandage scissor
Torniquet
Hypoallergenic/Micropore tape
Gauze
Hand towel
Soap
NANDA Handbook
Forms: RLE Notice
Skills Inventory
Physical Assessment
Performance Evaluation
Rubrics for Charting
Others: LR/DR/NB slip
OR slip
PRC form
REMARKS

___________________
Clinical Instructor

Form No.: TSU-COS-SF-08 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

PATIENT EDUCATION FORM

Name Area
Inclusive
Year Level RLE Group dates of
Rotation
Name of
Age Gender
Patient
Date
Diagnosis
Admitted
 MAIN CONCEPT / TOPIC:

Details of Patient Education Content:

Patient’s Signature / Significant Other’s Signature

Date Signed
Date Submitted

Form No.: TSU-COS-SF-09 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1

COLLEGE COPY

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

RELATED LEARNING EXPERIENCE (RLE) NOTICE

_______________
Date
Sir / Madam:

This is to inform you that Miss / Mr. __________________________________ of

BSN Level _____ Section _____ committed the following RLE policy violation:
_______________________________________________________________________
_______________________________________________________________________

Based on the existing RLE Policy and Guidelines, he / she is hereby given a disciplinary
action of: _______________________________________________________________
 Filed by: ___________________________
Clinical Instructor
(SIGNATURE OVER PRINTED NAME)

Shown and Served to Me: ______________________________________

(STUDENT’S SIGNATURE OVER PRINTED NAME)

Noted and Acknowledged: ___________________________________________

(PARENT’S / GUARDIAN’S SIGNATURE OVER PRINTED NAME)

NOTED: ______________________
Chairperson

=============================================
====
PARENT’S / GUARDIAN’S and STUDENT’S COPY

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

RELATED LEARNING EXPERIENCE (RLE) NOTICE

_________________
Date
Sir / Madam:

This is to inform you that Miss / Mr. __________________________________ of

BSN Level _____ Section _____ committed the following RLE policy violation:
_______________________________________________________________________
_______________________________________________________________________

Based on the existing RLE Policy and Guidelines, he / she is hereby given a disciplinary
action of: _______________________________________________________________

Filed by: ___________________________

Clinical Instructor
(SIGNATURE OVER PRINTED NAME)

Shown and Served to Me: __________________________________

(STUDENT’S SIGNATURE OVER PRINTED NAME)

Noted and Acknowledged: ___________________________________________

(PARENT’S / GUARDIAN’S SIGNATURE OVER PRINTED NAME)

NOTED: ___________________________________
Form No.: TSU-COS-SF-10 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
Chairperson
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Name: ____________________________________ Section/Group: ______________

Learning Outcome: The student will develop their clear and concise written requirement

RUBRIC FOR WRITTEN REPORT/ASSIGNMENTS

(Journals/Reaction/Learning Paper)
PERFORMANCE AREA HIGHLY PROFICIENT (5) PROFECIENT (4) LIMITED PROFECIENCY (3) POOR (2) RATING
Content Development -Content is accurate, focused -Content is somewhat -Contents somewhat vague or -Content is unclear and
and consistent accurate and fairly clear, only loosely related to the irrelevant
-Exhibits content and offers solid but less accurate writing tasks -Offers simplistic undeveloped
development of idea reasoning -At times may be off topic or support for ideas
-Unified with new and fresh -Contains some appropriate too broad with limited support
insights details and/or examples
Organization and Structure -Clear Introduction, body and -Supports the purpose -Some signs of logical -Poorly organized or
conclusion with effective -Sequence of ideas could be organization demonstrates serious
transitions improved -May have abrupt or problems with progression of
-Accurate Sequencing ecological shifts and ideas
ineffective flow of ideas -A written form of speech
Mechanical Convention -Essentially Error Free -Has some mechanical error -Repeated weaknesses in -Mechanical errors are so
Spelling, Grammar, mechanics severe that writing are hidden
Punctuation -Repeated pattern of flaws
Logical Thinking -Skillfully evaluates -Adequately demonstrates -Simplistic analysis of -Insufficient reasoning
a. Precision information gathered for reasonable relationship complex issue -Lacks of complexity of
b. Depth observation, experience, among ideas --Limited clarity and thought
c. Accuracy reflection or reasoning complexity of thought
d. Logic
Presentation Referencing -Looks neat and professional -Looks neat but violates one -Looks fairly neat but violate -Looks untidy and does not
MLA/APA Format -Accurate Citations or two formatting rules some formatting rule follow formatting rules
Shown to me : ___________________________ Clinical Instructor: _______________________________
Signature above printed name Signature above printed name
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Name: ____________________________________ Section/Group: ______________

RUBRIC FOR HEALTH TEACHINGS/ORAL REPORTS

Dimension Very Satisfactory (20) Satisfactory (10) Poor (5) Rating
Organization (20 pts) -Presentation is well organized with -Loss train of thought does not stay -Presentation shows organization
beginning, middle and end. There is with the proposed outline, or under purpose and/or clear
a strong organizing theme with clear connections are all attempted but not relationship as transitions
main ideas and transitions. made clean for audience.
-Starts on time
Content (20 pts) -Information is complete and -Research component is less evident -Details and examples are lacking or
accurate. Clear evidence of than distinguished category or not well chosen for the topics
research. resources are present but less than - Lacks evidence of research
adequate for assignment
Engagement (10 pts) -Presentation involves the audience -Audience is involved but inadequate -Does not involved the audience
allowing time for them to think and processing a response time is
respond provided.
Delivery (20 pts) -Voice is easy to hear -Audience is able to hear as a whole, -Presenter is difficult to hear
-Rates of speech are appropriate but then there are times when -Rates of speaking are too slow or
-Appropriate length, clear summary volume is not quite adequate. fast.
as provided -Time is appropriately used -Presentation lacks conclusion or
-Audience is involved in synthesizing -Conclusion inadequate time is not appropriately used.
the discussion.
Visual Aids/Handouts (20 pts) -Visuals Aids are well done -Visual are are adequate but does -A poor use of visual materials
interesting and meaningful not inspire engagement with the -No handouts provided
materials
Promptness (10 pts) -Submits before the deadline -Submits just on time Late submission
Shown to me: ________________________________ Clinical Instructor: ___________________________
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
NAME: ______________________________ Area: ____________
Inclusive Date of Evaluation: ________________ RLE Group: ______

RUBRICS FOR CHARTING

DIMENSION VERY GOOD (5) GOOD NEEDS SCORE
(3) IMPROVEMENT
(1)
ASSESMENT All subjective and Most subjective and Some subjective
objective data is objective data is and objective data
collected and recorded collected and is collected. There
using the appropriate recorded using the is an
terminology. Additional appropriate incomplete/absence
data is collected terminology. of the use of inquiry
through the use of Additional data is to collect
inquiry flawlessly, collected through the information relevant
applying knowledge use of inquiry to the disease and
about the disease and flawlessly, applying current health
the patient’s current knowledge about the condition.
health condition. disease and the
patient’s current
health condition.
DIAGNOSIS The Nursing The Nursing The nursing
diagnosis/collaborative diagnoses selected diagnosis selected
problems selected reflect the adequate reflect that no effort
reflect the accurate interpretation of the to interpret
interpretation of the subjective and information was
subjective and objective data applied resulting in
objective data analyzed but are not a flawed plan of
analyzed. Subjective always the best care. PES/PE/Risk
and Objective are choice from the diagnosis format is
listed appropriately as possible diagnosis usually not
supporting data for the that could be complete or used
nursing diagnoses. All interpreted from the format correctly.
nursing diagnoses data. PES/PE/Risk
used NANDA diagnosis format is
Terminology. All actual used correctly.
nursing diagnoses
used 3 or 2 part
statements (PES/PE
format, Risk nursing
diagnosis use 2 part
statements)
PLANNING Measurable criteria are Most of the outcome Some of the
identified all of the time criteria are outcome criteria
and contain verb and measurable and are identified to achieve
time element. The identified to achieve goals will lead to the
criteria identified goals will lead to the resolution or control
 generally are resolution or control of the related
individualized and will of the related factors factors that
lead to the control of that contribute to the contribute to the
related factors that nursing diagnosis. nursing diagnosis
contribute to the purely by
nursing diagnosis coincidence and
poorly/erroneously
developed.
INTERVENTIO Specific interventions Specific interventions Interventions
N can easily be linked to can be linked to a developed are
specific outcomes. The specific outcome. incomplete.
interventions are The interventions are Inappropriate
realistic and realistic and intervention may be
appropriate to the appropriate to the included in the plan
patient’s current patient’s current of care.
status. health status.
EVALUATION The appropriate The appropriate Subjective and
subjective and subjective and objective data is
objective data is objective data is selected to reflect
selected through selected most of the evaluation without
review of the time, through review consideration of the
interventions related to of the interventions outcome criteria.
ongoing assessment. related to ongoing Subjective and
The subjective and assessment that objective data may
objective data that reflects adequate not be collected and
measures the outcome analysis. lacks consideration
is collected and of the outcome that
analyzed correctly. is required to be
measured. Data
collection was not
subjected to
analysis.

TOTAL SCORE:
Transmuted Grade:

__________________________
Student’s Signature and Date

__________________________
Clinical Instructor’s Name and Signature
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

WARD: ______________________________ Date: ____________

Year and Section: ________________ RLE Group: ______

STUDENT NURSE-PATIENT INFORMATION SHEET

STUDENT PATIENT ROOM DIAGNOSIS

______________________
Clinical Instructor
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Phase I Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

SURGICAL CIRCULATING in_____________________________________________

Hospital, Municipality/City/Province
Prepared by:
__________________________________
Printed Name and Signature of Student Operating Room Form 1B
Operating Room Circulating
Form

DATE PERFORMED AND PATIENT’S INITIAL ONLY SURGICAL PROCEDURE O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Name and Signature)
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

SURGICAL SCRUB in_____________________________________________

Hospital, Municipality/City/Province
Prepared by:
__________________________________
Printed Name and Signature of Student Operating Room Form 1A
Operating Room Scrub Form
MAJOR OPERATION

DATE PERFORMED AND PATIENT’S INITIAL ONLY SURGICAL PROCEDURE O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Name and Signature)
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Phase I Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

SURGICAL SCRUB in_____________________________________________

Hospital, Municipality/City/Province
Prepared by:
__________________________________
Printed Name and Signature of Student Operating Room Form 1A
Operating Room Scrub Form
MINOR OPERATION

DATE PERFORMED AND PATIENT’S INITIAL ONLY SURGICAL PROCEDURE O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Name and Signature)
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

IMMEDIATE NEWBORN CORD CARE in_____________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
__________________________________
Printed Name and Signature of Student ICNB FORM
IMMEDIATE CARE OF THE
NEWBORN

DATE PERFORMED AND PATIENT’S INITIAL ONLY IMMEDIATE NEWBORN O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER CARE PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Not applicable for Birthing/Lying-in, Indicate where performed (e.g. D.R., (if Midwife on Duty, signature not (Name and Signature)
Clinics/Homes) Nursery, NICU or Homes) required)
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

ACTUAL DELIVERY in_____________________________________________

Hospital/Home/Lying-in, Municipality/City/Province
Prepared by:
__________________________________
Printed Name and Signature of Student DR FORM
ACTUAL DELIVERY FORM

DATE PERFORMED AND PATIENT’S INITIAL ONLY PROCEDURE O.R. NURSE ON DUTY SUPERVISED BY
TIME STARTED CASE NUMBER PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
(Not applicable for Birthing/Lying-in, (if Midwife on Duty, signature not (Name and Signature)
Clinics/Homes) required)