Medication Administration Record

Student’s Name
Area Name of Dosage Classification Mechanism Adverse Nursing
/Date the Frequency of Action Reaction Considerations
Drug Preparation

Evaluator’s Signature:________________________________

Date: ____________________

N.B. To be filled with the administered medication only (W1, W2 and L&D) and corrected and signed by
the supervising instructor during the same administration day.

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 Student’s Activity Checklist for Maternal and Fetal Medicine Unit (MFMU)

Student’s name:

Objective Done Not Done Primary Nurse Comment

Signature
1. Abdominal palpation

2. CTG Application

3. Ultrasound observation

4. Biophysical profile
observation

5. Health teaching about iron

deficiency anemia

6. Health teaching about GDM

(Gestational diabetes mellitus).

Evaluator’s Signature:

Date:

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 Student’s Activity Checklist for Obstetrics and Gynecology Clinics (OPD)
Student’s name: _______________
Activity Signature of Technical Comment
assistant/OPD supervisor
Assists with admission of woman:
 Obtain nursing obstetrical/gynecological
history.
 Measure vital signs and FHR.
 Urine test.
 Weight.
 Height.
 Blood glucose.
Assists in OPD with:
 Prepare woman for procedure.
 Chaperon vaginal examination.
Educates woman on the following topics:
 Well baby care.
 Nutrition in pregnancy.
 Ante-natal care.
 Post-natal care.
 Medication in pregnancy.
 Breastfeeding.

Evaluator’s Signature: _____________________Date:__________________________

Arrangements for OPD: Students need to wait in front of Ward 2 to be submitted by the faculty to the
setting (Do not go by yourself)

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 Maternal History Sheet
Age:
Husband’s Occupation:
Height:

Vital Signs:
Temp:
PR:
RR:
BP:

Obstetric History
LMP: EDD:
Obstetric code:
Gravida:
Para:
Term:
Preterm:
Abortion:
Living:
Past Pregnancies
Year Mode of Delivery Gender Complications

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Past Medical History (Write detailed history including dates and treatment)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Allergy:
Blood transfusion: Smoking: ____________________
Medications:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Past Surgical History:

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Family History:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Current diagnosis:
______________________________________________________________________________________
______________________________________________________________________________________

N.B. To be filled on an antenatal case and submitted on the same exposure date to be corrected then submit
the corrected one with the antenatal nursing care plan on the same case.

Evaluator’s Signature:_____________________________
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 Date: ____________________________

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 POSTNATAL ASSESSMENT RECORD

Student’s name: ___________________

Mother's Name: ___________________Diagnosis: _________________________________________________Date: ___________________

Date Vital Fundus Lochia Output Breast Perineum Nursing Observation, Care and
/Time Signs Education
T Firmness Amount Urine Nipple Intact

P Engorgement Episiotomy

Position Color Bowel Movement R

BP E

Type of Diet Colostrum or E

Milk
D
RR Height Consistency Lower Extremities A

Edema Breast Tear

Varicose veins Feeding
Odor Homan’s sign
Type of Tear

Frequency

Evaluator’s Signature:___________________

N.B. Should be filled during the same exposure day then submitted for correction by the end of the same exposure day.
Evaluator’s Signature:

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 Nursing Care Plan (Antenatal)
Student’s Name :-------------------------------------
Mother’s Name:--------------------------------------- Date & Time of Admission----------------------
Diagnosis:-----------------------------------------
Nursing Evidenced by Expected Nursing Evaluation
Diagnosis Outcomes Interventions
( 0.5 mark) ( 0.5 mark) ( 0.5 mark) ( 3 marks) ( 0.5 mark)

Guidelines
 To be sketched on the same maternal history case and submitted for scoring within one week
from the exposure with the maternal history sheet

Evaluator’s Signature:___________________
Date: ______________________
Total marks: /5

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 Nursing Care Plan (Postnatal)
Student’s Name: __________________________
Mother’s Name: __________________________ Date & Time of Admission:______________
Diagnosis: __________________________ Mode of Delivery: __________________________

Nursing Evidenced by Expected Nursing Evaluation

Diagnosis Outcomes Interventions
( 0.5 mark) ( 0.5 mark) ( 0.5 mark) ( 3 mark) ( 0.5 mark)

Guidelines
 To be sketched on the same postnatal assessment case and submitted for scoring within one
week from the exposure with the corrected postnatal assessment record.

Evaluator’s Signature-------------------------
Date------------------------------------------
Total marks /5

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Clinical performance evaluation and instructor feedback

Student Name: _________________________________Student ID:______________________________

Clinical Rotation/Unit: ___________________________________________________________________
Rotation Period: _________________________________________________________________________
Date of Evaluation: ______________________________________________________________________

PERFORMANCE MARKING KEY

SCORE LEVEL OF PERFORMANCE

(0) Unsafe performance, significant omission in relevant

Unsatisfactory theoretical knowledge, requires frequent external cues from
mentor

(1) Performs safely, understands and applies most relevant

Fair theoretical knowledge, occasionally requires external cues
from mentor

(2) Performs safely, understands and applies relevant

Satisfactory theoretical knowledge, requires no external cues from
mentor

NA Not applicable

Final Mark: ________________________________________________________________________

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To ensure clinical competence and achievement of the intended clinical objectives, your daily clinical performance
and professionalism will be evaluated against specific criteria as the following:
CLINICAL PERFORMANCE EVALUATION TOOL
[ 0: Unsatisfactory 1: Fair 2: Satisfactory N/A: Not applicable ]
PERFORMANCE CATEGORY SCORE
0 1 2 N/A
I KNOWLEDGE/COGNITIVE
1 Displays critical thinking in analysis of health problems through relevant
discussions.
2 Demonstrates special knowledge for the patient / in the unit.
II NURSING PROCESS
1 Assessment skills
1.1 Obtains complete health history.
1.2 Performs complete physical assessment.
1.3 Analyzes and interprets assessment data and report if needed.
1.4 Demonstrates the ability to relate the data with patient’s current condition.
2 Planning skills
2.1 Identifies the actual and potential care needs.
2.2 Prioritizes the care needs.
2.3 Develops appropriate care plan keeping in mind the priority.
3 Implementation skills
3.1 Follows appropriate safety and infection control practices.
3.2 Prepares necessary equipment and environment.
3.3 Ensures the patient is ready for the required care.
3.4 Performs the planned nursing interventions.
3.5 Provides appropriate health education to patient and / or family.
3.6 Demonstrates competence in performing the required clinical skill(s).
4 Evaluation skills
4.1 Evaluates the effectiveness of care.
5 Documentation skills
5.1 Documents completely and effectively.
Sub Total/12

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 III INTERERSONAL SKILLS AND RESPONSIBILITIES
1 Leadership skills
1.1 Demonstrates initiative, interest in learning and doing tasks.
2 Islamic Value, Ethical, Legal and Professional Standards
2.1 Maintains proper uniform, grooming and appropriate nursing tools.
3. Responsibility, Accountability and Lifelong Learning
3.1 Demonstrates punctuality.
4 Collaboration with Multidisciplinary Team
4.1 Communicates effectively with instructors, colleagues and health team.
5 Communication
5.1 Establishes and maintains rapport with woman (and/or family).
Sub Total/5
Total/17

Comments:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Name of Faculty: ________________________________ Signature: _____________________

Name of Field Staff Member/CTA: __________________ Signature: _____________________
Student Signature: _____________________

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