Author: ..

PENGIRAN ANAK PUTERI RASHIDAH SA’ADATUL BOLKIAH
INSTITUTE OF HEALTH SCIENCE
DIPLOMA IN NURSING
23rd INTAKE (2009—2011 SESSION)
NURSING MANAGEMENT
SEMESTER 7
CLINICAL PLACEMENT/ ATTENDANCE RECORD

Student’s full name :
Mentor’s full name :
Ward :

Aim :
The aim of this clinical placement is to :
a) Develop student’s basic skills on ward management.
Requirement :
Each student is required to :
a) Work closely with his/her mentor for at least two shifts per
week throughout his/ her clinical placement.
b) Take charge of a shift of duty within the ward/ clinic or
planned occasions under the supervision of his/her as
signed mentor.
c) Obtain his /her mentor’s or nurse in charge signature to
wards the end of every shift to confirm him/her
attendance on the clinical attendance sheet provided.
d) Submit the clinical assessment record book to the year
three coordinators on completion of the clinical
placement.
To mentors :
Please kindly complete the assessment record with the student and make your overall comments or views on the student’s performance on the items/skills Your contribution in this regard is very much appreciated and valued.
Grading :
Achieved : have achieved the outcomes;and is same and
competent.
Not achieved : outcomes not achieved . Specify reason
N/A : not available in the speciality
N/0 : no opportunity
N/S : attempted but not safe.

Individualized patient / client care—ability to deliver nursing care/performing nursing skills.
Specific outcomes : -
Student should be able to :

Skill / performance	Achieved	Not Achieved	Remarks
a) perform admission/discharge and transfer of patient.
b) perform a thorough nursing assessment of the patient.
c) identify patient’s nursing problems , form a plan of care, implement and evaluate the patient’s care
d) show competence in giving nursing care with all relevant skills.
e) show safety and competence in performing nursing procedures under supervision.
f) effectively assists medical / officer.
g) work with the legal and ethical framework of nursing.
h) other achievement (please specify

Mentor’s evaluation / comments :
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
______________________________________________
______________________________________________

2. Communication skill—ability to communicate and interact .
Specific outcomes : -
Student should be able to :

Skill / performance	Achieved	Not Achieved	Remarks
understand, receive and give / accurate verbal and written report / on patients.
write clear, accurate and effective / records of care.
show understanding of human / behavior.
communicate effectively through / listening, speaking, writing and / non –verbal.
share information effectively with / other nursing staff/ health care / team.
f) other achievement (please specify)

Mentor’s evaluation / comments :
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
______________________________________________
______________________________________________

3. Coordination of care
Specific outcomes : -
Student should be able to :

Skill / performance	Achieved	Not Achieved	Remarks
a) deal effectively with emergencies and urgent situations.
b) assess priorities of care.
c) effectively work with other health / care team.
d) work effectively in a team with / other nursing staff.
seek guidance from others in / situations beyond the scope of / practice.
f) coordinate care for a group of / patients.
g) give and receive assistance given / and to others.
identify problems and make the necessary referral.
assign staff effectively for patient / care
h) other achievement (please / specify) :

Mentor’s evaluation / comments :
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
______________________________________________
______________________________________________

4. Professional nursing role.
Specific outcomes : -
Student should be able to :

Skill / performance	Achieved	Not Achieved	Remarks
show professional appearance and manner; wears uniform smartly; neat and well groomed appearance.
be punctual on and off duty and for meal breaks.
follow roster correctly
show professional responsibility of being a nurse.
work within the legal and ethical framework of nursing; work within limits of the student role and maintain confidentiality.
identify learning needs and adapt / to new situation.
g) other achievement (please / specify)

Mentor’s evaluation / comments :
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
______________________________________________
______________________________________________

5. Nursing management skill
Specific outcomes : -
Student should be able to apply effectively the basic theory and practice of management on the following aspects :

Skill / performance	Achieved	Not Achieved	Remarks
a) demonstrate leadership skills.
utilize nursing management / principles and practice.
motivate staff to give skilled care / to all patient.
maintain a high quality care of / nursing care.
e) .manage time effectively.
f) solve problem effectively.
g) prioritize care effectively.
identify resources for patient needs.
patient safety.
j) ward safety
k) ward comfort and cleanliness

cont …………………… Nursing Management Skill

Skill / performance	Achieved	Not Achieved	Remarks
l) check and / or order :
medications for ward use / ward / stock
drugs under DDA
emergency trolley
equipments such as suction ma / chine , ECG machine , sterile / equipments , nebulizer, etc
materials such as linen, gowns, / blankets , sterile cotton wool and / gauze , syringe and needles, / catheter, etc.
patient’s diet (general and spe / cific )
stationary
carry out investigations and / procedures.
facilitate ward round with doctors / and other health professionals.
o) other achievemennts (please specify)

Mentor’s evaluation / comments :
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
______________________________________________
______________________________________________

Mentor’s evaluation

Orientation interview ( first week)
Date given : …………………………………..
Mentor’s signature : ……………………Students signature :………………

Half - way progress feedback interview
Comment :
Date given :…………………………. Mentor’s signature :…………………

Final interview
Comment :

Total number of day absent : ………………… MC : ………………………
Mentor’s signature : …………………………..Date : ……………………….
Student’s signature : …………………………. Date : ……………………...

Mentor’s evaluation : 2nd placement (if applicable)

Orientation interview ( first week)
Date given : …………………………………..
Mentor’s signature : ……………………Students signature :………………

Half - way progress feedback interview
Comment :
Date given :…………………………. Mentor’s signature :…………………

Final interview
Comment :

Total number of day absent : ………………… MC : ………………………
Mentor’s signature : …………………………..Date : ……………………….
Student’s signature : …………………………. Date : ……………………...

Student’s attendance record

Month: ………August ……

Month: ………September ……

Month: ………October ……

Month: ………November ……

Month: ………December ……

Column : Put the dates of your clinical attachment.
Row : Tick the following terms :
√ = Present SD = Study Day
X = Absent L = Late
P = Permission PH= Public Holiday
MD=Making Up Day MC= medical certificate

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Name of Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Mentor / signature

PERMISSION RECORD

Date	Time In	Time Out	Reason— To attach letter	Mentor / Tutor / signature

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Previous booklet/ edited by SHAS2010

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