ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA

MENTAL STATUS EXAMINATION - EVALUATION FORMAT

Name of the student : Course :
Hospital and ward : Date and Time :
Diagnosis : Name of the Evaluator :
S.NO. CRITERIA MAX. MARKS OBTAINED MARKS

1 Patient profile 2

2 Content organization 15

▪ General appearance and 2

behavior

▪ Speech 2

▪ Mood and affect 2

▪ Thought process 2

▪ Perception 2

▪ Cognitive assessment 3

▪ Insight 2

3 Communication skills 3

4 Technique used 3

5 Summary conclusion 2

Total Marks 25

Remarks:

Signature of the
Evaluator

ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA

FORMAT FOR DRUG FILE

INDEX
S.No. Trade Pharmacological Dose MOA Indications Contraindications Side Nurses
Name Name and Effects Responsibility
Route

Reference.

ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA

 - EVALUATION FORMAT
Name of the student Course :
Hospital and ward Date and Time :
Diagnosis Name of the Evaluator :

DRUG PRESENTATION
Name of the student :
Course :
Hospital and ward :
Date and Time :
Diagnosis :
Name of the Evaluator :
S.NO. CONTENT 5 4 3 2 1

1 Identification of data

2 Informant

3 Information with reliability and validity

4 Presenting complains / Problem and their

duration
5 History of present illness (HOPI)

6 Objectives of process recording

7 • First Interview (Specific objectives,

Rapport ,Skill, Technique)
8 • Second Interview
Criteria should apply as per the first
interview
9 • Third Interview
Criteria should apply as per the first
interview
10 Maintain criteria for writing process
recoding able to write recoding ,format,
complete, accurate, organization
Total

Remarks:
Marks Obtained:-

Signature of the
Evaluator
 - EVALUATION FORMAT
Name of the student Course :
Hospital and ward Date and Time :
Diagnosis Name of the Evaluator :
ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA

PROCESS RECORDING
Name of the student :
Course :
Hospital and ward :
Date and Time :
Diagnosis : Name of the
Evaluator :

S.NO. CRITERIA MAX. OBTAINED

MARKS MARKS
CONTENT

1 Selection of drug 3

2 Explanation of mechanism of action 5

3 Knowledge in drug interaction 3

4 Explanation about nurse’s responsibility 5

5 Overall content 2

6 Overall presentation 2

7 A.V aids 3

8 Summary and Conclusion 2

Total Marks 25
 - EVALUATION FORMAT
Name of the student Course :
Hospital and ward Date and Time :
Diagnosis Name of the Evaluator :
Remarks:

Signature of the Evaluator

ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA
NURSING CARE PLAN
Name of the student :
Course :
Hospital and ward :
Date and Time :
Diagnosis : Name of the
Evaluator :

S.NO. CRITERIA MAX. OBTAINED

MARKS MARKS
CONTENT
1 General information 1
2 Nursing assessment
▪ History collection
▪ Physical examination 4
▪ Mental status examination
▪ Process recording
3 Investigations 1
4 Psychotropic drugs 2
5 List of problems identified 3
6 Nursing diagnosis (Acc. to priority ) 3
7 Nursing intervention by applying specific 5
principles
8 Evaluation of nursing care 2
9 Psycho education 2
10 Progress notes 1
 - EVALUATION FORMAT
Name of the student Course :
Hospital and ward Date and Time :
Diagnosis Name of the Evaluator :
11 Conclusion and bibliography 1
Total Marks 25

Remarks:

Signature of the Evaluator

ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA

NURSING CASE STUDY

Name of the student :

Course :
Hospital and ward :
Date and Time :
Diagnosis : Name of the Evaluator :

S.NO. CRITERIA MAX. OBTAINED

MARKS MARKS
CONTENT
1 General information 2
2 Nursing assessment
▪ History collection
▪ Physical examination 4
▪ Mental status examination
▪ Process recording
3 Investigations 1
4 Psychotropic drugs 2
5 Knowledge about disease 3
 - EVALUATION FORMAT
Name of the student Course :
Hospital and ward Date and Time :
Diagnosis Name of the Evaluator :
6 Comparison of patient picture and book 3
picture
7 Nursing process 5
8 Psycho education 2
9 Data from records 2
10 Conclusion and bibliography 1
Total Marks 25

Remarks:

Signature of the Evaluator

 ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA

NURSING CASE PRESENTATION - EVALUATION FORMAT

Name of the student : Course :
Hospital and ward : Date and Time :
Diagnosis : Name of the Evaluator :
S.NO. CRITERIA MAX. OBTAINED MARKS
MARKS
CONTENT
1 General information 2
2 Nursing assessment
▪ History collection
▪ Physical examination 4
▪ Mental status examination
▪ Process recording
3 Investigations 1
4 Psychotropic drugs 2
5 Knowledge about disease 3
6 Comparison of patient picture and book 3
picture
7 Nursing process 5
8 Psycho education 2
9 Presentation
▪ Patient involvement 1
i. Student involvement ii. 1
Personal involvement 1
10 Data from records 2
11 Conclusion and bibliography 1
Total Marks 25

Remarks:

Signature of the Evaluator

ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA

 HEALTH EDUCATION - EVALUATION FORMAT
Name of the student : Course :
Year : Date :
Subject : Time :
Topic : Name of the Evaluator :
S.NO. CRITERIA MARKS OBTAINED REMARKS
ALLOTED MARKS
Content, Planning and 05
Organization
A Objectives of Plan 01
B Outline and sequence of 01
arrangements
C Presentation of content 01
D Adequacy and coverage of content 01
E Rapport with patient and group 01
Presentation 20
A Introduction- relevant and 02
motivating
B Appearance 02
(well groomed, calm, organized
pleasant)
i. Conduct with group / 02
individual
ii. Clear speech 02
iii. Voice 02
iv. Simple to complex 02
v. Relevant 02
vi. Knowledge 02
vii. Control of environment 02
viii. Confidence related to 02
topics
ix. Questioning technique 02
A.V. AIDS 20
i. Creativity 02
ii. Attractive and holds 03
viewers attention
 iii. Visibility of content 02
iv. Arrangements and script 03
v. Appropriate colour 02
combination
vi. Skills in usage 03
vii. Accuracy of content 02
viii. A.V. aids principles 03
followed
Coverage 05
i. Time coverage (completed 01
in time)
ii. Participation of the group 02
iii. Acknowledgement and 01
discussion
iv. Summary and conclusion 01
Total Marks 50

Remarks:

Signature of the Evaluator

ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA

ELECTRO CONVULSIVE THERAPY (ECT)

ECT history collection format:
1. Identification data

2. Present chief complaints

3. History of present illness

4. Treatment history

5. Past psychiatric and medical history

6. Family history

7. Personal history

8. Mental status examination

9. Diagnostic formulation

10. Physical examination

11. Assessment of patient’s and family’s knowledge of indication, side effects, therapeutic effects
and risks associated with ECT
12. Per ECT Care check list:
PER ECT CARE CHECK LIST YES NO

A Informed consent

B Assess vital signs

C Nil per mouth (6-8 hrs)

D Withhold night dose of drugs

E Withhold oral medication in the morning

F Head shampooing
G Remove jewellery, prosthesis, dentures, contact lens etc.
H Remove tight clothing
I Empty bladder and bowel just before ECT
J Pre ECT medication
13. Intra procedure care

14. Post procedure care

15. Draw the physical layout of an ECT room and describe it.

16. Enumerate the ECT equipment’s

17. List out the per-medication used in ECT

 ALSHIFA COLLEGE OF NURSING, PERINTHALMANNA
OCCUPATION THERAPY FORMAT
1. Demographic data
2. Brief Description of present illness
3. Brief Description of mental status examination
4. Treatment history
5. Objective for occupational therapy
6. Evaluation of the patient
a. Current level of functioning
b. Social functioning
c. Behavioral problems
7. Description of Occupational Therapy (Activities) Planned or Provided for Patient
Description of activities Therapeutic value

8. Layout of occupational room

9. Discuss the role of nurse in planning and organizing occupational therapies