PERFORMANCE APPRAISAL TOOL FOR STAFF NURSES

a) Name of staff ………………………………e) Date of joining…………………..

b) EMP id………………………………………f) Appraisal year…………………..
c) Designation ……………………………………………..
d) Name of in charge…………………………
e) Department …………………………………
f) Name of administrator………………………………

Rating

 Good - 53-78
 Satisfactory – 27-52
 Unsatisfactory – 0-26

SR.NO. PARAMETERS SCORING

Average Good Excellent
a) Grooming professional conduct
i. Uniform neat and tidy 1 2 3
ii. Well – groomed 1 2 3
iii. Punctuality 1 2 3
iv. Behaviour with patients and attendants 1 2 3
v. Behaviour with seniors , colleagues and 1 2 3
other hospital staff
b) Communication/ administrative and professional knowledge
i. Fluency in official language and telephone 1 2 3
etiquettes
ii. Communication with patients and relatives 1 2 3
iii. Taken interest in ward supervision 1 2 3
iv. Self confidence and leadership quality 1 2 3
v. Conducts administrative and nursing 1 2 3
rounds
c) Basic nursing / clinical and advance nursing procedures
i. Performs basic care 1 2 3
ii. Skilled in invasive line insertion 1 2 3
iii. Performs nursing process 1 2 3
iv. Assisting in bedside procedures 1 2 3
v. Operating HMIS 1 2 3
d) Medication administration / documentation /reporting
i. Knows about MOM policy 1 2 3
ii. Awareness about patients regime 1 2 3
iii. Awareness about emergency drugs and its 1 2 3
uses
iv. Knows about medication error , near miss 1 2 3
and ADR
v. Awareness about process of blood 1 2 3
transfusion and its reaction
e) Policies and protocols
i. Hospital infection control policies 1 2 3
ii. Biomedical waste management protocols 1 2 3
iii. Knows about quality control indicators and 1 2 3
KPI
iv. Process to triaging and emergency color 1 2 3
codes
v. Skilled in CPR 1 2 3
vi. Knows about incident reporting and 1 2 3
escalation of issue process

Sign of staff Sign of in charge Sign of administrator

RECOMMENDATIONS :

a) PROMOTION

Please tick if the employee can be promoted to next level and grade

If yes,

a) indicate additional responsibilities

…………………………………………………………………………………………
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b) special recommendations and outstanding task taken up
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
c) training need identification
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………………....

For the HR use only

Remarks and signature Remarks and signature

(initiating officer ) (reporting officer )

Approved increment Promotion

Others Approval by board