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Republic of the Philippines

Professional Regulation Commission
BOARD OF NURSING
P. Paredes St., Corner N. Reyes St., Sampaloc, Manila, Philippines 1008
Web Address: www.prc.gov.ph / www.bonphilippines.org
Telephone No. (+632) 735 1534 Fax No. (+632) 735 4476

ANNEX TO PRC-BON MEMORANDUM CIRCULAR NO. 01 Series 2009

Subject ``` : New Intra-Partal, Immediate Care of the Newborn, and

Intra-operative Forms

Applicability : BSN Students and Graduates covered by CHED Memorandum Order

No. 14, s. 2009

DESCRIPTION OF FORMS

In accordance with PRC-BoN Memorandum No. 01, series 2009 the

following forms shall be submitted to the Commission on Higher Education
(CHED) by Nursing Colleges as evidence of obtaining Intra-Partal,
Immediate Care of the Newborn, and Intra-Operative Care Competencies
by nursing students and graduates covered by CMO No. 14, s. 2009 for
purposes of securing “special orders” for graduation together with other
CHED requirements:

1. Summary Performance Evaluation for Intra-Partal Care Competency

2. Summary Performance Evaluation for Immediate Care of the Newborn
Competency
3. Summary Performance Evaluation for Intra-Operative Care Competency

Kindly follow the new BoN Prescribed Performance Evaluation Forms as well as
the Student Summary CASE FORMs.

The Case Forms may be printed back-to-back with the appropriate Competency
Performance Evaluation Forms or the school may choose to adopt separate
printing modes according to the discretion of the Nursing College
Administration.

For Intra-Operative Competencies there must be 3 scrub cases and 3

circulating cases as per BoN Memorandum No. 1 series 2009.

Forms are to be accomplished in TRIPLICATE copies (1 for the College

Registrar, 1 for CHED, 1 for the Student)

Board of Nursing
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BOARDOF NURSING

Hon. Carmencita M. Abaquin

Chairperson

Hon. Leonila A. Faire Hon. Perla G. Po

Member Member

Hon. Betty F. Merritt Hon. Marco Antonio C. Sto Tomas

Member Member

Hon. Yolanda C. Arugay Hon. Amelia B. Rosales

Member Member

Board of Nursing
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University Nursing
Logo College
Logo
_____________________________________________
University
College of Nursing
(Exact Business Address, Tele-Fax No. and E-Mail Address)

SUMMARY PERFORMANCE EVALUATION ACHIEVING

INTRA-PARTAL CARE COMPETENCY
In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Signature over Printed Name of Student: ___________________________________________

INTRAPARTAL COMPETENCIES DESIRED ACTUAL

RATING RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Obtains obstetrical history including parity, gravida score, 4
LMP, EDC, AOG, BOW onset of true labor.
2. Checks vital signs. 1
3. Conducts physical examination. 2
4. Performs Leopold’s maneuver. 2
5. Checks Fetal Heart Rate and Fundic height. 2
6. Monitor progress of labor/ uterine contractions as to:
 Frequency 1
 Duration 1
 Intensity 1
 Interval 1
7. Observes for the timely rupture of membrane. 1
8. Coaches mother on process of labor. 2
PERFORMS FUNCTIONS DURING ACTUAL LABOR
1. Transports clients safely while providing privacy. 1
2. Places mother in lithotomy position. 1
3. Performs perineal care using sterile technique correctly. 1
4. Performs proper hand scrub. 1
5. Wears gown and gloves according to hospital policy. 1
6. Performs Ritgen’s maneuver safely. 2
7. Coaches mother on breathing and pushing techniques. 1
8. Delivers baby and placenta carefully.
 Checks and manages cord recoil correctly 1
 Clamps and cuts the cord correctly 1
 Identify signs of placental separation 1
 Checks the characteristic/ completeness of the placenta 1
9. Assesses amount of blood loss (Normal: <500 cc) 2
10. Employs interventions to achieve and maintain a well
contracted uterus to prevent/control hemorrhage.
 Uterine massage 1
 Correct administration of oxytocin 1
 Cold compress 1
11. Assesses presence and degree of laceration. 1
12. Assists in episiorrhaphy. 1
13. Checks size, consistency and location of uterus. 1

Board of Nursing
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INTRAPARTAL COMPETENCIES
14. Performs perineal care and applies pad correctly. 1
15. Provides emotional support to the mother throughout labor 1
and delivery.
16. Evaluates patient’s condition and records pertinent data 2
accordingly.
17. Prepares patient for transfer to recovery room/ ward.
1
II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)
1. Prepares room, instruments and equipment needed.
 Sterile drape 1
 Sterile instruments and equipment [Forceps, scissors, bulb 1
syringe, gauze, suture, needle holder, catheter (optional)]
 Kelly pad 1
 Disinfectant 1
2. Performs sterilization procedure. 1
3. Maintains adequacy of supplies as the delivery progresses. 1
4. Maintains orderliness of the sterile table. 1
5. Observes precautionary measures related to use of 1
electrical equipment.
6. Ensures a quiet environment. 1
7. Uses supplies diligently. 1
8. Performs after care of the materials and equipments used. 1
9. Ensures proper disposal of hospital waste including blood 1
and other fluids.
III. HEALTH EDUCATION (HE)
1. Teaches client on basic preparation during labor and 1
deliver (can be done in the labor room)
2. Coaches’ client on breathing/ bearing down technique. 2
3. Demonstrates proper “latch-on” breast feeding technique 1
(done post-partum period).
4. Gives instructions to parents regarding infant care before 1
discharge (done post-partum period.)
5. Provides discharge instructions as to feeding, bathing, 1
administration of ordered medications, appointment dates
for post natal and well baby check up (done post-partum
period.)
6. Responds to questions of clients and relatives regarding 1
expectations.
IV. LEGAL RESPONSIBILITIES (LR)
1. Secures informed consent in all procedures related to labor 1
and delivery.
2. Reports accurately and honestly the gender, time of 2
delivery of the baby and placenta.
3. Ensures proper identification of the mother and newborn. 2
4. Documents all pertinent data correctly and completely. 1
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the religious, cultural and ethnic practices of the 1
family of the woman in labor and delivery.
2. Promotes emotional security by supporting needs. 1
3. Ensures privacy and confidentiality. 1
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Updates oneself with the latest trends and development in 1
labor and delivery.

Board of Nursing
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INTRAPARTAL COMPETENCIES
2. Projects a professional image of a delivery room nurse. 1
3. Accepts criticisms and recommendations. 1
4. Performs functions according to standards. 1
VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences)
1. Identifies deviation of practice from the standards. 1
2. Participates in audit practices in the delivery room/lying in. 1
3. Recommends corrective and preventive measures for the 1
identified deviations.
VIII. RESEARCH (R) (preferably done during post conferences)
1. Identifies researchable problems related to labor and 2
delivery.
2. Utilize findings of research studies in intra-partal care. 2

IX. RECORDS MANAGEMENT (RM)

1. Documents accurately relevant data about client. 1
2. Maintains an organized system of filing and keeping 1
records of the client.
X. COMMUNICATION (Comm)
1. Utilizes appropriately all forms of communication; verbal, 1
non-verbal, electronic.
2. Inform client’s significant others of the progress of labor and 1
delivery.
3. Listens attentively to clients and families queries and 1
requests.
XI. COLLABORATION AND TEAMWORK (CTW)
1. Functions effectively as a team player in the delivery 1
room/lying in.
2. Communicates the progress of labor/delivery to significant 1
others.
3. Establishes collaborative relationship with members of the 1
health team and family members.
TOTAL SCORE: 90

Certified True and Correct:

(Signature over Printed Names)

________________________________________ ______________________________________
Clinical Instructor Clinical Coordinator
License Number: _________________________ License Number: _______________________
PRC Card - Validity Date: __________________ PRC Card – Validity Date: ________________

________________________________________
DEAN ______________________________________
License Number: _________________________ Academic Year Graduated
PRC Card - Validity Date: __________________

Board of Nursing
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University Nursing
Logo College
Logo
SUMMARY PERFORMANCE EVALUATION ACHIEVING
IMMEDIATE CARE OF THE NEWBORN COMPETENCY
In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Signature over Printed Name of Student: ___________________________________________

NEWBORN COMPETENCIES DESIRED ACTUAL

RATING RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Establishes and maintains patent airway. 3
2. Puts the newborn in Trendelenburg position. 1
3. Suctions mouth and nose of the newborn gently. 2
4. Dries newborn and wraps warmly. 1
 Places under droplight as needed
5. Performs and interprets APGAR scoring correctly.
 Immediately after delivery 2
 After 5 minutes 2
6. Ensures proper identification of newborn (name tag: name 2
of mother, date and time of delivery, gender and name of
attending physician).
7. Performs physical assessment including anthropometric 4
measurements including weight, height, head, chest,
abdominal circumference.
8. Takes vital signs (temperature per rectum to check 1
patency)

9. Gives oil/ water and soap bath according to institutional 1

policy.
10. Latches newborn to the mother’s breast immediately after 1
birth.
11. Applies CREDE’s prophylaxis on the eyes. 1
12. Performs cord dressing aseptically.
 Disinfects area properly according to hospital policy 1
 Clamps and cuts cord 1 inch from the abdomen 1
 Checks for the presence of 2 arteries and 1 vein 1
 Dresses cord aseptically according hospital policy 1
13. Administers Vitamin K (1 mg/M) into the lateral anterior 1
thigh or vastus lateralis.
14. Keeps baby wrapped warmly under floor lamp or beside 1
mother according to institutional policy until discharge.
15. Records pertinent observations and nursing care done. 1
16. Reports any signs of deviation/abnormality to the 1
pediatrician.
II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)
1. Prepares instrument and equipment needed
 Suction bulb, cord clamp, gauze, cotton balls, 4
disinfectant, blanket, droplight, Vitamin K, antimicrobial
ophthalmic ointment.
2. Ensures use of sterile equipment during immediate care 1
of the newborn.

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3. Maintain adequacy of supplies as newborn care is 1

rendered
4. Maintains orderliness of the working area. 1
5. Observes precautionary measures related to use of 1
electrical equipment.
6. Ensures a warm and quiet environment. 1
7. Uses supplies diligently. 1
8. Ensures proper disposal of hospital waste. 1
III. HEALTH EDUCATION (HE)
1. Provides instructions to the mother on daily cord care and 2
prevention of cord infection.
2. Provides discharge instructions to the mother on when to 1
expect cord to fall off or to report signs of cord infection.
3. Provides information regarding newborn screening, 2
immunization, feeding, etc.
4. Responds to questions of mother and relatives regarding 1
expectations.
IV. LEGAL RESPONSIBILITIES (LR)
1. Identifies newborn by comparing ID band with data in the 2
chart.
2. Documents all pertinent data correctly and completely. 1
3. Reports accurately any deviations/abnormal findings and 1
nursing interventions rendered.
4. Ensures that birth certificate and other civil registration 2
forms are accomplished/ filled out according to
institutional policy.
5. Performs foot printing according to hospital policy. 1
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the religious, cultural and ethnic practices of the 1
family of the newborn.
2. Maintains privacy and confidentiality of findings of 1
assessments.
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Updates oneself with the latest trends and developments 1
in newborn care.
2. Projects a professional image of the pediatric nurse. 1
3. Accepts criticisms and recommendations. 1
4. Performs functions according to standards. 1
VII. QUALITY IMPROVEMENT (QI)
1. Identifies deviation of practice from the standards. 1
2. Participates (whenever possible) in audit practices in the 1
nursery.
3. Recommends corrective and preventive measures for the 1
identified deviations.
VIII. RESEARCH (R)
1. Identifies researchable problems related to immediate 2
care of newborn.
2. Utilizes findings of research studies in the immediate care 2
of the newborn.
IX. RECORDS MANAGEMENT (RM)
1. Documents accurately relevant data about the newborn. 1
2. Maintains an organized system of filing and record 1
keeping.

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X. COMMUNICATION (Comm)
1. Utilizes appropriately all forms of communication; verbal, 1
non-verbal, electronic.
2. Maintains an open line of communication with the mother 1
and other family members.
3. Informs mother of relevant information about the newborn. 1
4. Listens attentively to queries and requests of mothers and 1
family members.
XI. COLLABORATION AND TEAMWORK (CTM)
1. Functions effectively as a team player in the nursery. 1
2. Communicates findings of assessment to all concerned. 1
3. Establishes a collaborative relationship with members of 1
the health team and family of the newborn.
TOTAL SCORE: 75

Certified True and Correct:

(Signature over Printed Names)

________________________________________ ______________________________________
Clinical Instructor Clinical Coordinator
License Number: _________________________ License Number: _______________________
PRC Card - Validity Date: __________________ PRC Card – Validity Date: ________________

________________________________________
DEAN ______________________________________
License Number: _________________________ Academic Year Graduated
PRC Card - Validity Date: __________________

Board of Nursing
University Nursing
Page
Logo9 of 10 College
Logo
________________________________________________________
University
College of Nursing
(Exact Business Address, Tele-Fax No. and E-Mail Address)

SUMMARY PERFORMANCE EVALUATION ACHIEVING

INTRA-OPERATIVE CARE COMPETENCY
In Accordance with PRC Board of Nursing Memorandum No. 01 Series 2009

Signature over Printed Name of Student: ___________________________________________

st nd rd
INTRA-OPERATIVE CARE COMPETENCIES DESIRED 1 2 3 AVERAGE
RATING RLE RLE RLE RATING
I. SAFE AND QUALITY NURSING CARE (SQC)
1. Utilizes the nursing process in the care of OR
client
a. Obtains comprehensive client’s information 4
by checking complete accomplishment of
the preoperative checklist/client’s chart
b. Identifies priority needs of the client at the 4
Operating Room
c. Provides needed nursing interventions 4
based on identified needs
d. Monitors client’s responses to surgery 2
2. Promotes safety and comfort of patients inside 2
the OR
3. Performs the functions of the scrub nurse
a. Performs surgical scrub correctly 4
b. Wears sterile gowns and gloves aseptically 2
c. Prepares surgical instruments, sponges, 2
sutures and other supplies in functional
arrangement
d. Hands instruments, sponges, sutures and 2
other needed materials according to
surgeon’s preference
e. Performs surgical count accurately 2
4. Performs the functions of the circulating nurse
a. Anticipates the needs of the surgical team 2
b. Sets up the OR room and needed 2
equipment
c. Receives client for surgery / endorses client 2
post –operatively
d. Assists in skin preparation and draping of 2
client
5. Administers medications and other 2
health therapeutics safely
II. MANAGEMENT OF RESOURCES AND ENVIRONMENT (MRE)
1. Organizes work load to facilitate timely patient 4
Care
2. Utilizes adequate and appropriate resources to 2
support the OR team
3. Ensures functionality of OR resources 2
4. Maintains a safe environment at the OR by 2
observing the principles of asepsis
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III. HEALTH EDUCATION (HE)

1. Implements appropriate health education 2
activities to client based on needs assessment
IV. LEGAL RESPONSIBILITIES (LR)
1. Adheres to legal and institutional protocols 2
regarding informed consent
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the rights of the OR client 2
2. Accepts responsibility and accountability for own 2
decisions and actions as an OR nurse
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Performs OR functions according to professional 4
standards
2. Possesses positive attitude towards learning 2
surgical and OR-related knowledge and skills
VII. QUALITY IMPROVEMENT (QI)
1. Participates in quality improvement activities 2
related to infection control and successful OR
operations
2. Identifies and reports variances in sterility and 2
other OR activities
VIII. RESEARCH (R)
1. Disseminates results of OR-related research 2
findings to clinical group and other members of
the OR team
as appropriate
IX. RECORDS MANAGEMENT (RM)
1. Maintain accurate and updated documentation of 2
patient care
X. COMMUNICATION (Comm)
1. Establishes rapport with patients, significant 1
others and members of the health team
2. Uses appropriate information mechanisms to 2
facilitate communication inside the OR and with
other departments in the hospital
XI. COLLABORATION AND TEAMWORK (CTM)
1. Collaborates plan of care with other members of 2
the health team
TOTAL SCORE 75

Certified True and Correct:

(Signature over Printed Names)

________________________________________ ______________________________________
Clinical Instructor Clinical Coordinator
License Number: _________________________ License Number: _______________________
PRC Card - Validity Date: __________________ PRC Card – Validity Date: ________________

________________________________________
DEAN ______________________________________
License Number: _________________________ Academic Year Graduated
PRC Card - Validity Date: __________________

Board of Nursing