Ippms

Office Performance Output Table
OASPER
January - December 2013
STRATEGIC PRIORITY
MFO / KDP Measures Targets Success Indicators Accountable Division
KDP: Defense Resource Management System, Defense System of Management
Quantity 1 HR / CD Plan developed 1 HR / CD Plan completed before the start of
DND Proper HR / CD Plan Timeliness completed before the start of the calendar year the calendar year with 100% acceptability HRDD
Quality 100% acceptability upon 3 presentations upon 3 presentations
Quantity 1 APB developed 1 APB developed within prescribed
OASPER APB Timeliness within prescribed timeframe timeframe with 100% acceptability upon 3 HRDD
Quality 100% acceptability upon 3 presentations presentations
CORE FUNCTION
MFO 1: Human Resource / Career Development Interventions
Quantity 1 approved training calendar per year
1 approved training calendar per year to be
Annual Training Calendar Timeliness completed before the start of every calendar year completed before the start of every CY and HRDD
90% achievable and workable
Quality 90% achievable and workable as perceived by clients
Quantity 1 approved list of foreign and local training programs 1 approved list of foreign and local training
List of Foreign and Local Training programs to be completed before the start of
Timeliness completed before the start of every calendar year HRDD
Programs every CY and 90% responsive to DND HRD
Quality 90% responsive to DND HRD needs as perceived by clients needs
Quantity 17 approved training designs
17 training designs approved upon 2
completed within 3 days for simple and 5 days for complex presentations for simple and 4 for complex
Training Designs Timeliness HRDD
designs
designs to be completed within 3 days for
upon 2 presentations for simple and 4 presentations for simple and 5 days for complex designs
Quality
complex designs
Quantity 33 trainings conducted
33 trainings conducted and accomplished
Trainings Conducted Timeliness accomplished within the approved training calendar within the approved training calendar with HRDD
90% training requirements achieved
Quality 90% training requirements achieved
Quantity 100% of local and foreign travel assisted 100% of local and foreign travels assisted
Timeliness within 1 day for urgent / priority and 3 days for regular within 1 day for urgent / priority and 3 days
Local and Foreign Travels Assisted for regular approved upon 2 presentations HRDD
upon 2 presentations for urgent / priority and 3 presentations for urgent / priority and 3 presentations for
Quality regular
for regular
MFO 2: Human Resource Management Interventions
Quantity 100% of required personnel actions undertaken undertaken 100% of required personnel
Civilian Personnel Actions Timeliness within set deadline actions within set deadline and prescribed CPD
Quality within prescribed quality quality
Quantity 100% of documents acted upon 100% of documents acted upon within 3
Timeliness within 3 days for priority and 5 days for regular documents days for priority and 5 days for regular
Military Personnel Actions MPD
within 3 allowable revisions for both priority and regular documents with 3 allowable revisions for
Quality both priority and regular documents
documents
MFO 3: HR Policy / Program Design Implementation, Monitoring, and Evaluation
Quantity 90% of personnel data inputted and 100% updated 90% of personnel data inputted and 100%
HR Information System Timeliness inputted within 2 days upon receipt of data updated within 2 days upon receipt of data CPD
Quality within 5% allowable error rate with 5% allowable error rate
MFO 4: HR Policy Review and Reformulation
Quantity 1 handbook drafted 1 handbook drafted within the prescribed
Handbook on Military HR Laws and
Timeliness within the prescribed timeline timeline with 100% acceptability upon 3 MPD
Policies
Quantity updated IPPMS guidelines approved updated IPPMS guidelines approved within
Updated IPPMS Timeliness within set deadline set deadline with 100% acceptability upon 3 CPD
Quantity 3 Integrity Development Policies developed 3 Integrity Development Policies developed

Integrity Development Policies Timeliness within the prescribed timeline within the prescribed timeline with 100% CPD
acceptability upon 3 presentations
Quality 100% acceptability upon 3 presentations
Quantity 5 GAD Policies developed 5 GAD Policies developed within the
GAD Policies Timeliness within the prescribed timeline prescribed timeline with 100% acceptability
Quantity 2 KAPAGDAKA Policies developed 2 KAPAGDAKA Policies developed within
KAPAGDAKA Policies Timeliness within the prescribed timeline the prescribed timeline with 100% MPD
Quality 100% acceptability upon 3 presentations acceptability upon 3 presentations
Quantity updated Citizen's Charter approved updated Citizen's Charter approved within
Updated Citizen's Charter Timeliness within set deadline set deadline with 100% acceptability upon 3 CPD
Quantity 1 HR Plan developed 1 HR Plan completed within the prescribed
HR Plan Timeliness within the prescribed timeline timeline with 100% acceptability upon 3 CPD
Quantity updated GIP / OJT guidelines approved updated GIP / OJT guidelines approved
Updated GIP / OJT Guidelines Timeliness within set deadline within set deadline with 100% acceptability HRDD
SUPPORT FUNCTION
MFO 5: Admin and Support Services
Quantity 1 Document Tracking System designed 1 Document Tracking System designed
Document Tracking System Design Timeliness within set deadline within set deadline with 90% responsiveness OD
Quality 90% responsiveness to clients' needs to clients' needs
Quantity 100% requested supplies delivered 100% requested supplies delivered within 2
Office Supplies Management Timeliness within 2 days upon request days upon request with 90% acceptability of OD
Quality 90% acceptability of supplies delivered supplies delivered
Quantity 100% budgeting and financial requirements acted upon 100% budgeting and financial requirements
Office Financial Services Timeliness within set deadline acted upon within set deadline with 100% OD
acceptablity upon 2 revisions
Quality 100% acceptability upon 2 revisions
Quantity 100% of requested transport needs supplied 100% of requested transport needs supplied
Office Transport Operations OD
Timeliness within specified timeframe upon request
within specified timeframe upon request
(FORM B)
OFFICE PERFORMANCE COMMITMENT AND REVIEW (OPCR)

I, COLONEL MARIA VICTORIA P JUAN NC (GSC), Chief Nursing Service Division, VLGH, commit to deliver and agree to be rated on the attainment of the following targets in accordance
with the indicated measures for the period 01 July to 31 December, 2015.
COLONEL MARIA VICTORIA P JUAN NC (GSC)
Head of Office
Date:
Reviewed by Date Confirmed by Date
LTC ANTONIO G PUNZALAN MC (GSC) COLONEL EDWIN LEO T TORRELAVEGA MC (GSC)

Executive Officer, VLGH Commanding Officer, VLGH
Approved by* Date
COLONEL SANTIAGO I ENGINCO PA (GSC)

Chief of Staff, AFPMC
5 - Outstanding
4 - Very satisfactory
3 - Satisactory
2 - Unsatisfactory
1- Poor
SUCCESS INDICATORS (TARGETS + Actual Rating

MFO/PAP Allotted Budget Division Accountable Remarks
MEASURES) Accomplishments Ql1 Qn2 T3 A4
STRATEGIC PRIORITY
To provide tertiary health care
5426 patients treated per semester VLGH
services
CORE FUNCTIONS
MFO 1: Quality nursing care 85% Level of Satisfaction of all patients towards nurses
per month NSD
services
SUPPORT FUNCTIONS
MFO 2: Admin and Support Services
70% Average Score from the Level of Satisfaction
Personnel Satisfaction of All Nursing Personnel at the end of the year Clinical Br
70% of all personnel action request accomplished

Personnel Action Request within (3) working days Admin Br
70% of All Personnel appraisal is accomplished and
Personnel Appraisal submitted with 0 errors in format within one month after Admin Br
the rating period
70% of all the Nursing Personnel disciplinary

Personnel Discipline actions monitored and recorded per month Clinical Br
100% of All Issued Supplies for 24 hours are

Sterile Supplies Processing Sterile CSR
100% of all Nursing Personnel's attendance and

Attendance and Punctuality punctuality will be recorded and monitored per Clinical Br
month
90% of approved schedule of ALL clinical areas

Detail Publication distributed (3) days before the end of the month Clinical Br
MFO 3: Education and Training Services
70% of all Nursing Personnel will undergo Skills Education and Training
Competency Report Competency Checklist biannually Br
70% of RN Residents will pass the program

Education and Training
RN-Residency Program requirements prior to completion at the end of the
semester Br
70% of the RLE exposures of nursing students Education and Training

Affiliation are implemented as programmed per semester Br
70% of P2LTs will pass the Course requirements

Mentoring Program prior to program completion after the six month
period Br
70% of students will pass the Course

AFP Nurse Corps Specialty requirements prior to program completion after
Training Course one year period Br
70% of Nursing Personnel should attend at least

Staff Development Program (3) approved nursing service training programs
biannually Br
70% of Clinical Areas satisfactorily presented case Education and Training

Case Study Report studies biannually Br
Nursing Service Education and 70% of the training plans and programs are Education and Training
Training Program conducted and completed annually Br
MFO 4: Quality Assurance and Research Support Service
90% of the Nursing Clinical areas passed the
Nursing Audit Report Nursing Audit at the end of the semester NR&QA
At least 2 policies reviewed, revised, and
Nursing Policies and Procedures formulated with 0 errors in format at the end of the NR&QA
semester
70% of Nursing Personnel satisfactorily passed

Infection Control Domain Audit the Infection Control Domain Audit at the end of HICC
the semester
Integrated Disease Surveillance 70% of the Clinical Areas submits the PIDSR form
on time every week with 0 errors in format HICC
and Response
All sentinel events are Collected, Analyzed, and

Hospital Event Report Reported with 0 errors in format at the end of the NR&QA
semester
70% of Nurses satisfactorily participate in

Evidence-Based research research activities at the end of the semester NR&QA
CORE FUNCTION MFO 1: Quality nursing care services

SUPPORT FUNCTIONS MFO 2: Admin and Support Services
MFO 3: Education and Training Services
MFO 4: Quality Assurance and Research Support Services
TOTAL AVERAGE POINT SCORE
OVERALL EQUIVALENT NUMERICAL RATING
OVERALL EQUIVALENT ADJECTIVAL RATING
Assessed by: Confirmed by: Final Rating by: Date
LTC ANTONIO G PUNZALAN MC (GSC) COL EDWIN LEO T TORRELAVEGA MC (GSC) COLONEL SANTIAGO I ENGINCO PA (GSC)
Ex-O, VLGH CO, VLGH Head of Agency
Date: Date:
Legend: 1 - Quality (Ql) 2 - Quantity (Qn) 3 - Timeliness (T) 4 - Average (A)

(FORM C)
ROLE-RESULTS MATRIX
__NURSING SERVICE DIVISION - WARD 4 C GENITOURINARY _
_______________July to December 2015_______________
Chief Nurse, VLGH Admin and Support Services Mentoring and Training Program Quality Assurance and Research Clinical Care
Monthly Report Training Recommendation Environment of Care Checklist Staff Distribution
LTC ARLENE V GUTIERREZ NC (GSC) Leave Request Staff Orientation (Newly Hired) Incident Reports Patient Care Supervision
Assistant Chief Nurse for Clinical Care Performance Evaluation Ward Activities Monitoring
In-patient Census Report
Attendance Report Environment of Care Checklist VIP report
Notice of Discipline Incident Reports In-patient Census Report
Clinical Area Supervisor
Performance Evaluation Staff Distribution
Supplies and Equipment Management
2LT NOVIE CARLA G PAGADUAN NC

Head Nurse
Ms Arlene Sales RN II
Assistant Head Nurse
(Nurse II, SG-15)
Ms Jennifer Parajes RN II
Case Manager (Nurse II, SG-15)
Mr Claresto Rhuir Bas-awan RN I

Staff Nurse I (Nurse I, SG - 11)
Ms Yolanda Vasquez NA
(Nursing Attendant I, SG-8)
Ms Angeles Lapinig NA
Ms Mary Rose Regaspi NA

MERIT / DEMERIT POINTS
CRITERIA MERIT DEMERIT
POINTS 0.75 0.5 0.25 0.75 0.5 0.25
Attendance / 0 - 1 authorized and informed (3 > 3 authorized or 4 - 6 unauthorized or 3 unauthorized or uninformed absence (3
hours before duty) absence with no unauthorized per month for 3 uninformed absence hours before duty)
Punctuality tardiness and no notices loafing for consecutive months or 3 (3 hours before duty)
the whole rating period months per rating period;
6 uninformed (3 hours
before duty) or unauthorized
absence for the whole rating
period
19 & above tardiness for the 12 - 18 tardiness for 9 tardiness for the whole rating period
whole rating period the whole rating
period
11 & above notices of loafing 6 - 10 notices of 5 notices of loafing

loafing
Disciplinary Offenses 1 Grave and / or 2 less 1 Less Grave 4 Light Offenses with Oral Warning
Grave Offenses and / or 9 Offense and / or 6
Light Offenses with a Light Offense with
Reprimand or higher Written Warning
Disciplinary Action (Admonition)
Disciplinary action
Non - compliance to Submits Leave Application 7 & above notices for Late or 4 - 6 notices for Late 3 notices for Late Submission for the
requests, DTR, Nursing Unit Non-compliance to or Non-compliance whole rating period
Submission Reports, Letter of Explanation, Submission for the whole to Submission for
Incident Reports, other rating period the whole rating
documents as instructed before period
given deadline
Performance of Performing duties of a higher position Tasked in Nursing Service or Performing duties of lower
Command Directed Program or position
Designated Function Activities
Tasked as member of Technical

Working Group or Committees
Performed > 16 hours cumulative

Training Instructor and > 8 hours
Lecturer duties
Individual Work Output Table
____Office of the Nursing Service _____
_____________________________________________
________Nurse II SG-15 (Assistant Head Nurse)_________
___________Clinical Care Branch - Infectious Ward (Medical)_______
PERFORMANCE SUCCESS INDICATOR PERFORMANCE STANDARDS

Major Final Outputs PERFORMANCE TARGETS Outstanding Very Satisfactory Satisfactory Unsatisfactory Poor
MEASURES Measures + Targets
1. Endorsement Book
Quality with complete details 100% of patients, within 100% of patients, within 100% of patients, within 100% of patients, within <100% of patients, within <100% of patients, within
Received all patients with complete details within the
Timeliness within first hour of the shift the first hour of shift, with the first hour of shift, with 61-70 minutes, or with 1 71-80 minutes, or with 2-3 81-90 minutes, or with 4-5 >90 minutes, or with 6 or
first hour of the shift
Quantity all patients 0 (zero) missed data. 0 error. error. errors. errors. more errors.
2. Patient Assessment Progress Notes
Quality No errors in Standard Protocols <100% of patients more <100% of patients more than
Completed Nursing Assessment Protocol of all 100% of patients within 24 100% of patients within 24 100% of patients within 24 100% of patients within 48
Timeliness completed within 24 Hours than 48 hours or with 4-5 48 hours or with 6 or more
Patient within 24 hours hours with 0 (zero) error. hours with 0 (zero) error. hours with 1 error. hours or with 2-3 errors.
Quantity all patients errors errors
3. Nursing Care Plan
Quality No error <100% of patients more <100% of patients more than
Completed Nursing Care Plan of all patients within 100% of patients within 24 100% of patients within 24 100% of patients within 24 100% of patients within 48
Timeliness completed within 24 Hours than 48 hours or with 4-5 48 hours or with 6 or more
24 hours hours with 0 (zero) error. hours with 0 (zero) error. hours with 1 error. hours or with 2-3 errors.
Quantity all patients errors errors
4. Medication Administration Record
Quality No error
Completed Medication Protocol of all patients within 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within <100% of patients within shift
Timeliness completed within shift
shift shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift or with 2 errors. shift or with 3 errors or with 4 or more errors
Quantity all patients
5. Nursing Procedures Defficiency Monitoring Record
Quality No error
Completed Nursing Procedures Standard Protocol of 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within <100% of patients, within
Timeliness completed within shift
all patients within shift shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors shift with 6 or more errors
6. Health Teaching Record
Quality No error 100% of patients upond 100% of patients upon <100% of patients, upon
Completed Health Teaching Protocol of all patients 100% of patients upon 100% of patients upon <100% of patients upon
Timeliness completed upon discharge discharge with 0 (zero) discharge with 0 (zero) discharge with 6 or more
upon discharge discharge with 1 error. discharge with 2 errors. discharge with 3-5 errors
Quantity all patients error. error. errors
7. Nursing Progress Notes
Quality No error
Completed Nursing Progress Notes of all patients 100% of patient within 100% of patient within shift 100% of patient within shift 100% of patients within <100% of patients within <100% of patients within shift
Timeliness within shift
within shift shift with 0 (zero) error. with 0 (zero) error with 1 eror. shift with 2 errors. shift with 3-5 error with 6 or more errors
8. ISOBAR Defficiency Record
Quality No error
Completed ISOBAR Standard Protocol of all patients 100% of patient within 100% of patient within shift 100% of patient within shift 100% of patients within <100% of patients within <100% of patients within shift
Timeliness within shift
within shift shift with 0 (zero) error. with 0 (zero) error. with 1 error. shift with 2 errors. shift with 3-5 errors with 6 or more errors
9. Emergency Cart Equipment Record
Quality No error 100% of Emergency Cart 100% of Emergency Cart 100% of Emergency Cart 100% of Emergency Cart <100% of Emergency Cart
Complete accounting of Emergency Cart Equipment <100% of patients within shift
Timeliness within shift Equipment within shift Equipment within shift with Equipment within shift with Equipment within shift Equipment within shift with
within shift with 6 or more errors
Quantity all E-cart equipments with 0 (zero) error. 0 (zero) error. 1 error. with 2 errors. 3 errors.
10. Case Study/Research Paper
excellent substance, with 0-1
Quality Incomplete requirements, Incomplete requirements,
missed data Complete requirements, Complete requirements, Complete requirements, Complete requirements,
insufficient substance unacceptable substance
Completed requirements for case study/ research Timeliness On or before deadline Excellent substance, on or Excellent substance, on or sufficient substance but 1- sufficient substance but
and/or 49-72 hours after and/or more than 72 hours
paper biannually before deadline with 0-1 before deadline with 0-1 24 hours after deadline 25-48 hours after deadline
deadline and/or 6-7 after deadline and/or more
Quantity Complete requirements missed data. missed data. and/or 2-3 missed data. and/or 4-5 missed data.
missed data. than 8 missed data
11. Nurse Manager Role Deficiency Checklist

Quality All tasks complied
<100% nurse manager tasks
<100% nurse manager
Timeliness upon deadline 100% nurse manager 100% nurse manager 100% nurse manager and/ormore than 49 hours
Performs administrative duties and responsibilities in 100% upon deadline with tasks and/or 24-48 hours
tasks upon deadline with 0 tasks upon deadline with tasks upon deadline with beyond deadline and/or with
the absence / behalf of the Head Nurse 0 (zero) error after deadline and/or with
(zero) error 1-2 errors 3-4 errors more than 7 uncomplied
Quantity all delegated tasks 5-6 errors
tasks
12. Assistive Nurse Manager Deficiency Record

Quality All tasks complied 100% delegated tasks 24- 100% delegated tasks more
100% delegated tasks 100% delegated tasks 100% delegated tasks 100% delegated tasks
Performs all administrative tasks as directed and as 48 hours after deadline than 49 hours beyond
Timeliness upon deadline upon deadline with 0 upon deadline with 0 upon deadline with 1-2 upon deadline with 3-4
delegated by the Head Nurse and /or with 5-6 deadline and/or with more
(zero) uncomplied tasks (zero) uncomplied tasks uncomplied tasks uncomplied tasks
Quantity all delegated tasks uncomplied tasks than 7 uncomplied tasks
(FORM E)
INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR)
I, MS. AURORA M DELA CRUZ RN II, of the Infectious Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in accordance with the
indicated measures for the period from July to December, 2015.
_______________________
Employee
Date: ___________________
Reviewed by Date Approved by Date
CPT KRISTINA L SALVADOR NC LTC CAROLINE D COMMENDADOR NC

Immediate Supervisor Head of Office
Rating
Output Success Indicator (Target + Measure) Actual Accomplishments Remarks
Ql1 Qn2 T3 A4
Core Function
100% of patients, within the first hour of shift, with 100% of patients, within 71-80 mins, with 0 missed data /
Endorsement Book 3 3 3 3
0 (zero) missed data error
Patient Assessment 100% of patients, within 24 hours with 0 (zero)
<100% of patients within 24 hours with 5 errors 2 2 2 2
Progress Notes error
100% of patients, within 24 hours with 0 (zero)

Nursing Care Plan 100% of patients within 24 hours with 2-3 errors 3 3 3 3
error
10Rs correctly observed and

Medication 100% of patients, within 24 hours with 0 (zero) Adheres to AFPMC Standard
100% of patients within 24 hours with 0 (zero) error 5 5 5 5
Administration Record error Protocols of Safe Medication
Administration
Nursing Procedures
Deficiency Monitoring 100%of patients, within shift with 0 (zero) error 100% of patients, within shift with 4-6 errors 2 2 2 2
Record
100% of patients, upon discharge with (0) zero
Health Teaching Record 100% of patients upon discharge with 1 error 4 4 4 4
error
Nursing Progress Notes 100% of patients, within shift with 0 (zero) error 100% of patients within shift with 2 errors 3 3 3 3
ISOBAR Deficiency Disorganized, Incomplete,

100% of patients, within shift with 0 (zero) error 100% of patients, within shift with 6 errors 1 1 1 1
Record Faulty Relay of Information
Support Function
Emergency Cart 100% of Emergency Cart Equipment within shift

100% of Emergency Cart Equipment, within shift with 2 errors 3 3 3 3
Equipment Record with 0 (zero) error
Case Study / Research Complete requirements, Excellent substance on or Complete requirements, Sufficient substance 25 -48 hours
3 3 3 3
Paper before deadline with 0 (zero) missed data after deadline with 2 missed data
Nurse Manager Role 100% nurse manager tasks upon deadline with 0
100% nurse manager tasks upon deadline with 5 errors 2 2 2 2
Deficiency Checklist (zero) error
Nurse Manager
100% delegated tasks upon deadline with 0 (zero) 100% delegated tasks upon deadline with 4 uncomplied
Assistant Deficiency 3 3 3 3
uncomplied tasks tasks
Checklist
Average point score 2.83 2.83 2.83 2.83
Overall point score 2.83
Intervening point score 0.25
Overall Equivalent Numerical Rating 3.08
Overall Equivalent Adjectival Rating Satisfactory
Comments and Recommendations for Development Purposes
Discussed with Date Assessed by Date Final Rating by Date

I certify that I discussed my assessment of the
performance with the employee
CPT KRISTINA L SALVADOR NC LTC CAROLINE D COMMENDADOR NC

Employee Supervisor Head of Office

_____________________________________________
________Nurse II SG-15 (Case Manager)_________
___________Clinical Care Branch - Female Surgical Ward________

1. Endorsement
Receives all Book
patients with Quality with complete details 100% of patients, within 100% of patients, within 100% of patients, within 100% of patients, within <100% of patients, within <100% of patients, within
complete details Timeliness within first hour of the shift the first hour of shift, with the first hour of shift, with 61-70 minutes, or with 1 71-80 minutes, or with 2-3 81-90 minutes, or with 4-5 >90 minutes, or with 6 or
within the first Quantity all patients 0 (zero) missed data. 0 error. error. errors. errors. more errors.
hour of
2. Patient the shift
Assessment Progress Notes
Completed Quality No errors in Standard Protocols
Nursing
Timeliness completed within 24 Hours <100% of patients more <100% of patients more
Assessment 100% of patients within 24 100% of patients within 24 100% of patients within 24 100% of patients within 48
than 48 hours or with 4-5 than 48 hours or with 6
Protocol of all hours with 0 (zero) error. hours with 0 (zero) error. hours with 1 error. hours or with 2-3 errors.
Quantity all patients errors or more errors
Patient within 24
hours
Completed Quality No error
Nursing Care Timeliness completed within 24 Hours <100% of patients more <100% of patients more
100% of patients within 24 100% of patients within 24 100% of patients within 24 100% of patients within 48
Plan of all than 48 hours or with 4-5 than 48 hours or with 6
hours with 0 (zero) error. hours with 0 (zero) error. hours with 1 error. hours or with 2-3 errors.
patients within 24 Quantity all patients errors or more errors
hours
Completed Quality No error
Medication Timeliness completed within shift <100% of patients within
100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within
Protocol of all shift or with 4 or more
shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift or with 2 errors. shift or with 3 errors
patients within Quantity all patients errors
shift
Quality No error
Completed Timeliness completed within shift
Nursing
<100% of patients, within
Procedures 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within
shift with 6 or more
Standard Protocol shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
Quantity all patients errors
of all patients
within shift

Quality No error
Completed Health Timeliness completed upon discharge 100% of patients upond 100% of patients upon <100% of patients, upon
Teaching Protocol 100% of patients upon 100% of patients upon <100% of patients upon
discharge with 0 (zero) discharge with 0 (zero) discharge with 6 or more
of all patients discharge with 1 error. discharge with 2 errors. discharge with 3-5 errors
Quantity all patients error. error. errors
upon discharge

Completed
Nursing Progress Quality No error <100% of patients within
100% of patient within 100% of patient within shift 100% of patient within shift 100% of patients within <100% of patients within
Notes of all Timeliness within shift shift with 6 or more
shift with 0 (zero) error. with 0 (zero) error. with 1 error. shift with 2 errors. shift with 3-5 errors
patients within Quantity all patients errors
8. ISOBARshiftDefficiency Record
Quality No error
Completed Timeliness within shift
ISOBAR <100% of patients within
100% of patient within 100% of patient within shift 100% of patient within shift 100% of patients within <100% of patients within
Standard Protocol shift with 6 or more
shift with 0 (zero) error. with 0 (zero) error. with 1 error. shift with 2 errors. shift with 3-5 errors
of all patients Quantity all patients errors
within shift

Quality No error
Complete Timeliness within shift
accounting of 100% of Emergency Cart 100% of Emergency Cart 100% of Emergency Cart 100% of Emergency Cart <100% of Emergency Cart <100% of patients within
Emergency Cart Equipment within shift Equipment within shift with Equipment within shift with Equipment within shift Equipment within shift with shift with 6 or more
Equipment within Quantity all E-cart equipments with 0 (zero) error. 0 (zero) error. 1 error. with 2 errors. 3 errors. errors
shift

Quality
error Incomplete
Completed
Complete requirements, Complete requirements, Complete requirements, Complete requirements, Incomplete requirements, requirements,
requirements for
Excellent substance, on or Excellent substance, on or very sufficient substance sufficient substance 25- insufficient substance 49- unacceptable substance
Incomplete
Completed
Complete requirements, Complete requirements, Complete requirements, Complete requirements, Incomplete requirements, requirements,
requirements for Timeliness On or before deadline Excellent substance, on or Excellent substance, on or very sufficient substance sufficient substance 25- insufficient substance 49- unacceptable substance
case study/
before deadline with 0-1 before deadline with 0-1 1-24 hours after deadline 48 hours after deadline 72 hours after deadline more than 72 hours after
research paper
error. error. and/or with 2-3 errors. and/or with 4-5 errors. and/or with 6-7 errors. deadline and/ or with
biannually Quantity Complete requirements more than 8 errors
11 NCP Template/Clinical Pathway template
Formulate/ Quality 0 error in format/substance

unacceptable substance
Revise/review 4 3 NCP templates 1-24 2 NCP templates 25-48 1 NCP templates 49-72
4 NCP templates within a 4 NCP templates within a more than 72 hours after
nursing care plan Timeliness within a month hours after a month and/or hours after a month hours after a month and/or
month with 0 error month with 0 error deadline and/or with
templates a with 1-2 error and/or with 3-4 error with 5-6 error
more than 8 errors
month Quantity 4 NCP templates
12. NCP Compliance Checklist
checks NCP Quality 0 error

compliance of <70% NCP upon
Timeliness upon discharge 100% NCP upon 100% NCP upon 90% NCP upon discharge 80% NCP upon discharge 70% NCP upon discharge
nurses to all discharge and/or with
discharge with 0 error discharge with 0 error and/or with 1-2 errors and/or with 3-4 errors and/or with 5-6 errors
patients upon more than 7 errors
discharge Quantity all NCP
(FORM E)
I, MS. AMI M MIZUNO RN II, of the Female Surgical Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in accordance with the
indicated measures for the period from July to December, 2015.
_______________________
Employee
Date: ___________________
CPT KARLA MINA N DELA ROSA NC LTC CAROLINE D COMMENDADOR NC

Rating
Ql1 Qn2 T3 A4
Core Function
100% of patients, within the first hour of shift, with Systematically done and
Endorsement Book 100% of patients, within the first hour of shift, with 0 error 5 5 5 5
0 (zero) missed data Well organized
Patient Assessment 100% of patients, within 24 hours with 0 (zero)
<100% of patients, more than 48 hours or with 4-5 errors 2 2 2 2
Progress Notes error
100% of patients, within 24 hours with 0 (zero) Incomplete and unfilled up

Nursing Care Plan <100% of patients, more than 48 hours or with 8 errors 1 1 1 1
error NCP
Adheres to the Patient
Safety Standards of
Medication 100% of patients, within 24 hours with 0 (zero)
100% of patients, within 24 hours with 0 (zero) error 5 5 5 5 Medication Administration
Administration Record error
and prudently observes the
10Rs
Nursing Procedures
Deficiency Monitoring 100%of patients, within shift with 0 (zero) error 100% of patients, within shift with 3 errors 3 3 3 3
Record
100% of patients, upon discharge with (0) zero
Health Teaching Record <100% of patients, within shift, with 4 errors 2 2 2 2
error
Nursing Progress Notes 100% of patients, within shift with 0 (zero) error 100% of patients, within shift with 1 error 4 4 4 4
ISOBAR Deficiency
100% of patients, within shift with 0 (zero) error 100% of patients, within shift with 1 error 4 4 4 4
Record
Support Function
Needs to be reminded to
Emergency Cart 100% of Emergency Cart Equipment within shift <100% of Emergency Cart equipment within shift, with 4
2 2 2 2 check the E-Cart stock
Equipment Record with 0 (zero) error errors
records, low on initiative
Case Study / Research Complete requirements, Excellent substance and Complete requirements, very sufficient substance 5 hours
4 4 4 4
Paper on or before deadline with 0 - 1 missed data before deadline with 2 missed data
NCP Template / Clinical

4 NCP templates within a month with 0 error 3 NCP templates 5 hours after a month with 1 error 4 4 4 4
Pathway template
Insufficient and incomplete

NCP Compliance NCPs, Needs improvement
100% NCP upon discharge with 0 error <70 % NCP upon discharge with 10 errors 1 1 1 1
Checklist on systematic time allocation
for NCP formulation

Overall Equivalent Adjectival Rating Very Satisfactory

CPT KARLA MINA N DELA ROSA NC LTC CAROLINE D COMMENDADOR NC


Nursing Service Division
_____________________________________________
________Nurse I, SG-11_________
___________Clinical Care Branch - Neuro-Surgical Ward (Ward 4A)________
PERFORMANCE STANDARDS
PERFORMANCE SUCCESS INDICATOR Measures
Major Final Outputs PERFORMANCE TARGETS
MEASURES + Targets Outstanding Very Satisfactory Satisfactory Unsatisfactory Poor
1. Endorsement Book
Quality with complete details
Receives all patients with 100% of patients, within the first 100% of patients, within 100% of patients, within 100% of patients, within <100% of patients, within <100% of patients, within
complete details within the Timeliness within first hour of the shift hour of shift, with 0 (zero) missed the first hour of shift, with 61-70 minutes, or with 1 71-80 minutes, or with 2-3 81-90 minutes, or with 4-5 >90 minutes, or with 6 or
first hour of the shift data. 0 error. error. errors. errors. more errors.
2. Patient Assessment Progress Notes
Quality No errors in Standard Protocols

Completed Nursing <100% of patients more <100% of patients more
Timeliness completed within 24 Hours 100% of patients within 24 hours 100% of patients within 24 100% of patients within 24 100% of patients within 48
Assessment Protocol of all than 48 hours or with 4-5 than 48 hours or with 6
with 0 (zero) error. hours with 0 (zero) error. hours with 1 error. hours or with 2-3 errors.
Patient within 24 hours errors or more errors
Quality No error
Completed Nursing Care 100% of patients within 48 <100% of patients more <100% of patients more
100% of patients within 24 hours 100% of patients within 24 100% of patients within 24
Plan of all patients within 24 hours and/ or with 2-3 than 48 hours and/or with than 48 hours and/or
Timeliness completed within 24 Hours with 0 (zero) error. hours with 0 (zero) error. hours and/or with 1 error.
hours errors. 4-5 errors with 6 or more errors
Quality No error
Completed Medication <100% of patients within
100% of patients within shift with 0 100% of patients within 100% of patients within 100% of patients within <100% of patients within
Protocol of all patients within Timeliness completed within shift shift or with 4 or more
(zero) error. shift with 0 (zero) error. shift with 1 error. shift or with 2 errors. shift or with 3 errors
shift errors

Quality No error
Completed Nursing Timeliness completed within shift <100% of patients, within
Procedures Standard 100% of patients within shift with 0 100% of patients within 100% of patients within 100% of patients within <100% of patients within
Protocol of all patients within (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
errors
shift Quantity all patients

Quality No error
Completed Health Teaching Timeliness completed upon discharge 100% of patients upon <100% of patients, upon
100% of patients upond discharge 100% of patients upon 100% of patients upon <100% of patients upon
Protocol of all patients upon discharge with 0 (zero) discharge with 6 or more
with 0 (zero) error. discharge with 1 error. discharge with 2 errors. discharge with 3-5 errors
discharge Quantity all patients error. errors
Quality No error
Completed Nursing Progress <100% of patients within
100% of patient within shift with 0 100% of patient within shift 100% of patient within shift 100% of patients within <100% of patients within
Notes of all patients within Timeliness within shift shift with 6 or more
(zero) error. with 0 (zero) error. with 1 error. shift with 2 errors. shift with 3-5 errors
shift errors
8. ISOBAR Deficiency Record
Quality No error
Completed ISOBAR Timeliness within shift <100% of patients within

100% of patient within shift with 0 100% of patient within shift 100% of patient within shift 100% of patients within <100% of patients within
Standard Protocol of all shift with 6 or more
(zero) error. with 0 (zero) error. with 1 error. shift with 2 errors. shift with 3-5 errors
patients within shift errors
Quality No error
Complete accounting of Timeliness within shift 100% of Emergency Cart 100% of Emergency Cart 100% of Emergency Cart 100% of Emergency Cart <100% of Emergency Cart <100% of patients within
Emergency Cart Equipment Equipment within shift with 0 (zero) Equipment within shift with Equipment within shift Equipment within shift Equipment within shift shift and/or with 6 or
within shift error. 0 (zero) error. and/or with 1 error. and/or with 2 errors. and/or with 3 errors. more errors
Quantity all E-cart equipments

excellent substance, with 0-1 Incomplete
Quality
error Complete requirements, Complete requirements, Incomplete requirements, requirements,
Complete requirements,
Completed requirements for Complete requirements, Excellent very sufficient substance sufficient substance insufficient substance unacceptable substance
Timeliness On or before deadline Excellent substance, on or
case study/ research paper substance, on or before deadline and/or 1-24 hours after and/or 25-48 hours after and/or 49-72 hours after and/or more than 72
before deadline with 0-1
biannually with 0-1 error. deadline and/or with 2-3 deadline and/or with 4-5 deadline and/or with 6-7 hours after deadline
error.
errors. errors. errors. and/or with more than 8
Quantity Complete requirements errors
I, MS. REI JEAN C DELA PENA RN I, of the Neuro-Surgical Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in
accordance with the indicated measures for the period July to December, 2015.
_______________________
Employee
Date: ___________________

CPT FELIX RICHARD I MENDOZA NC MAJ NELSON A MANONDO NC
Rating
Ql1 Qn2 T3 A4
Core Function
100% of patients, within the first hour of shift, with
Endorsement Book 100% of patients, within 65 minutes, or with no error. 4 4 4 4
0 (zero) missed data.
Patient Assessment 100% of patients within 24 hours with 0 (zero)

<100% of patients, within 48 hours or with 4 errors 2 2 2 2
Progress Notes error.
Medication
100% of patients within shift with 0 (zero) error. 100% of patients within shift with 1 error. 4 4 4 4
Administration Record
Nurisng Procedures Performs Nursing

Deficiency Monitoring 100% of patients within shift with 0 (zero) error. 100% of patients within shift with 0 (zero) error. 5 5 5 5 Procedures prudently
Record and competently
100% of patients upond discharge with 0 (zero)

Health Teaching Record 100% of patients, upon discharge with 0 (zero) errors 5 5 5 5 Educates eloquently
error.
Nursing Progress Notes 100% of patient within shift with 0 (zero) error. 100% of patients within shift with 1 error. 4 4 4 4
ISOBAR Deficiency
100% of patient within shift with 0 (zero) error. 100% of patients within shift with 2 errors. 5 5 5 5
Record
Support Function
100% of patients within 24 hours with 0 (zero)
Nursing Care Plan 100% of patients within 24 hours with 1 error. 4 4 4 4
error.
Emergency Cart 100% of Emergency Cart Equipment within shift 100% of Emergency Cart Equipment within shift with 1
4 4 4 4
Equipment Record with 0 (zero) error. error.
Incomplete requirements, unacceptable substance

Case Study / Research Complete requirements, Excellent substance, on
submitted more than 72 hours after deadline with 8 1 1 1 1 Needs Improvement
Paper or before deadline with 0-1 error.
errors
Intervening point score -0.75
Overall Equivalent Adjectival Rating Unsatisfactory
I do not conforme with the rating given to me. I have attached a letter of appeal on
this matter with substantial evidences to prove the rating Ms
otherwise.
Rei Jean C Dela Pena RN
I certify that I discussed my assessment of
the performance with the employee
MS. REI JEAN C DELA PENA RN I CPT FELIX RICHARD I MENDOZA NC MAJ NELSON A MANONDO NC

_____________________________________________
________Registered Midwiife II SG-11________
___________Clinical Care Branch - Obstetrics and Gynecology Ward________

MEASURES Measures + Targets Outstanding Very Satisfactory Satisfactory Unsatisfactory Poor
1. Vital signs/ I&O Monitoring Sheet

Quality accurate
monitors and Timeliness within shift 100% of patients, within 100% of patients, within <100% of patients, within
100% of patients, within 100% of patients, within <100% of patients, within
records accurate the shift, with zero (0) the shift, with zero (0) the shift or with 6 or
the shift, or with 1 error. the shift or with 2-3 errors. the shift or with 4-5 errors.
patient data Quantity all patients error error more errors.
2. NAP Critical Patient Reporting Deficiency Record
Quality accurate 100% of patients, within 100% of patients, within <100% of patients, within
report accurate 100% of patients, within 100% of patients, within <100% of patients, within
the shift, with zero (0) the shift, with zero (0) the shift or with 6 or
patient data Timeliness within shift the shift, or with 1 error. the shift or with 2-3 errors. the shift or with 4-5 errors.
error error more errors.
3. Labor Monitoring Sheet
Quality accurate
progress of patient Timeliness within shift the shift, with zero (0) the shift, with zero (0) the shift or with 6 or
labor error error more errors.
4. Midwife Procedures Deficiency Record

Quality No error
Completed midwife 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within
Timeliness completed within shift shift with 6 or more
procedures shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
errors
5. EINC Procedure Checklist Deficiency Record

Quality No error
Completed EINC <100% of patients, within
Timeliness completed within shift 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within
Procedure shift with 6 or more
shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
Checklist errors
6. NAP 5S Deficiency Record

Quality No error
Accomplished 5s
100% of all assigned 100% of all assigned 100% of all assigned 100% of all assigned <100% of all assigned <100% of all assigned
standard at all Timeliness completed within shift areas within shift with 0 areas within shift with 0 areas within shift with 1 areas within shift with 2 areas within shift with 3 areas within shift with 4
assigned areas
(zero) error. (zero) error. error. error. error. error.
within the shift Quantity all assigned areas
7. Clinical Area Equipment/Supply Record

Complete Quality No error
<100% of
accounting of 100% of 100% of supply/Equipment 100% of <100% of
Timeliness within shift 100% of supply/Equipment supply/Equipment within
clinical area supply/Equipment within within shift with 0 (zero) supply/Equipment within supply/Equipment within
within shift with 1 error. shift with 6 or more
supply/Equipment shift with 0 (zero) error. error. shift with 2 errors. shift with 3 errors.
Quantity all equipment and supply errors.
within shift
8. Midwife Administrative Deficiency Record

Quality No error
Timeliness completed within shift <100% of patients, within
administrative work shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
errors

Quality No error
Completed Health
Teaching Protocol Timeliness completed within shift 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within
of all patients upon shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
errors
discharge Quantity all patients
10. Research / HRDP - COPAR

Quality Incomplete
error
Completed Complete requirements, Complete requirements, Incomplete requirements, requirements,
Complete requirements, Complete requirements,
requirements for Timeliness On or before deadline very sufficient substance sufficient substance insufficient substance unacceptable substance
Excellent substance, on or Excellent substance, on or
case study/ and/or 1-24 hours after and/or 25-48 hours after and/or 49-72 hours after and/or more than 72
before deadline with 0-1 before deadline with 0-1
research paper deadline and/or with 2-3 deadline and/or with 4-5 deadline and/or with 6-7 hours after deadline
error. error.
biannually errors. errors. errors. and/or with more than 8
errors
requirements for very sufficient substance sufficient substance insufficient substance unacceptable substance
error. error.
biannually Quantity Complete requirements errors. errors. errors. and/or with more than 8
errors
I, MS. MARICEL F MORALES RM II, of the Obstetrics and Gynecology Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following
targets in accordance with the indicated measures for the period July to December, 2015.
_______________________
Employee
Date: ___________________
CPT ANNABELLE G DELA TORRES NC MAJ SERAFFIN L SORIANO NC

Rating
Ql1 Qn2 T3 A4
Core Function
Vital Signs / I&O 100% of patients, within the shift, with zero (0) Well appreciated by co-
100% of patients, within the shift, with zero (0) error 5 5 5 5
Monitoring Sheet error staff
NAP Critical Patient

100% of patients, within the shift, with zero (0)
Reporting Deficiency 100% of patients, within the shift, with zero (0) error 5 5 5 5 Well organized
error
Record

Labor Monitoring Sheet 100% of patients, within the shift, with zero (0) error 5 5 5 5 Comprehensive
error
Midwife Procedures Systematically

100% of patients within shift with 0 (zero) error. 100% of patients within shift with 0 (zero) error. 5 5 5 5
Deficiency Record performed
EINC Procedure
Well appreciated by co-
Checklist Deficiency 100% of patients within shift with 0 (zero) error. 100% of patients within shift with 0 (zero) error. 5 5 5 5
staff
Record
NAP 5S Deficiency 100% of all assigned areas within shift with 0 100% of all assigned areas within shift with 0 (zero)
5 5 5 5 Area well maintained
Record (zero) error. error.
Comprehensive and
Health Teaching Record 100% of patients within shift with 0 (zero) error. 100% of patients within shift with 0 (zero) error. 5 5 5 5 clearly understood by
patients
Support Function
Clinical Area
100% of equipment/ supply within shift with 0
Equipment / Supply 100% of patients within shift with 0 (zero) error. 5 5 5 5 Well maintained
(zero) error.
Record
Records, Cases, and

Midwife Administrative Birth Certificate Filing
100% of patients within shift with 0 (zero) error. 100% of patients within shift with 0 (zero) error. 5 5 5 5
Deficiency Record well maintained and
organized
Research / HRDP - Complete requirements, Excellent substance, on Complete requirements, Excellent substance, on or Relevant conducted
5 5 5 5
COPAR or before deadline with 0-1 error. before deadline with 0-1 error. research

Intervening point score - 0.75
Overall Equivalent Adjectival Rating Outstanding

MS. MARICEL F MORALES RM II CPT ANNABELLE G DELA TORRES NC MAJ SERAFFIN L SORIANO NC

_____________________________________________
___________Clinical Care Branch - Neonatal Intensive Care Unit (NICU)_____


Quality accurate
Quality accurate
Timeliness within shift the shift, with zero (0) the shift, with zero (0) the shift or with 6 or
patient data the shift, or with 1 error. the shift or with 2-3 errors. the shift or with 4-5 errors.
3. Neonatal Assessment Deficiency Record
Quality accurate
pediatric Timeliness within shift the shift, with zero (0) the shift, with zero (0) the shift or with 6 or
assessment error error more errors.

Quality No error
errors

Quality No error
Checklist errors

Quality No error
Accomplished 5s
assigned areas

<100% of
within shift

Quality No error
errors

Quality No error
Completed Health
errors

Quality Incomplete
error
error. error.
errors
error. error.
errors
I, MS. DORINA T SANCHEZ RM II, of the Neonatal Intensive Care Unit, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in
_______________________
Employee
Date: ___________________
CPT CERULLO P MANLAPAT NC MAJ THOMAS O DE CASTRO NC

Rating
Ql1 Qn2 T3 A4
Core Function
Vital signs/ I&O 100% of patients, within the shift, with zero (0)
100% of patients, within the shift, with 3 errors 3 3 3 3
Monitoring Sheet error

Reporting Deficiency 100% of patients, within the shift, or with 1 error. 4 4 4 4
error
Record
Neonatal Assessment 100% of patients, within the shift, with zero (0)
<100% of patients, within the shift or with 4 errors. 2 2 2 2
Deficiency Record error
Performs integrated
Midwife Procedures
100% of patients within shift with 0 (zero) error. 100% of patients within shift with 0 (zero) error. 5 5 5 5 maternal and child care
Deficiency Record
competently
EINC Procedure Was not able to

Checklist Deficiency 100% of patients within shift with 0 (zero) error. 100% of patients within shift with 8 errors. 1 1 1 1 accomplish most of the
Record EINC Checklist form
Health Education
rendered to patients on
Breast Feeding, Cord
Health Teaching Record 100% of patients within shift with 0 (zero) error. 100% of patients within shift with 0 (zero) error. 5 5 5 5 Care, Newborn Bathing
and Immunization follow
ups were conducted
comprehensively
Support Function
NAP 5S Deficiency 100% of all assigned areas within shift with 0

100% of all assigned areas within shift with 2 errors. 3 3 3 3
Record (zero) error.
Failed to report
Clinical Area unserviceable ward
100% of supply/Equipment within shift with 0
Equipment/Supply <100% of supply/Equipment within shift with 10 errors. 1 1 1 1 equipments, incomplete
(zero) error.
Record recording, stock cards
were not updated
Midwife Administrative
100% of patients within shift with 0 (zero) error. 100% of patients within shift with 2 errors. 3 3 3 3
Deficiency Record
Research / HRDP - Complete requirements, Excellent substance, on Complete requirements, Excellent substance, on or
5 5 5 5
COPAR or before deadline with 0-1 error. before deadline with 0-1 error.


MS. DORINA T SANCHEZ RM II RM II CPT CERULLO P MANLAPAT NC MAJ THOMAS O DE CASTRO NC


_____________________________________________
___________Clinical Care Branch - Pediatric Ward (W6C)_____


Quality accurate
Quality accurate
3. Pediatric Assessment Deficiency Record
Quality accurate

Quality No error
errors
5. Pediatric Growth and Development Program Reports

Quality Relevant <100% of conducted
100% of conducted 100% of conducted 100% of conducted 100% of conducted <100% of conducted irrelevant, insufficient
Relevant conduct
Timeliness On or before deadline relevant Integrated relevant Integrated relevant, sufficient relevant, sufficient irrelevant, insufficient substancePediatric
of all Integrated
Pediatric Growth and Pediatric Growth and substance Pediatric substance Pediatric substance Pediatric Growth and
Pediatric Growth
Development Programs Development Programs Growth and Development Growth and Development Growth and Development Development Programs
and Development
reported on or before reported on or before Programs reported and/or Programs reported and/or Programs reported and/or reported and/or more
Programs Quantity all program reports deadline deadline 1-24 hours after deadline 25-48 hours after deadline 49-72 hours after deadline than 72 hours after
deadline

Quality No error
Accomplished 5s
assigned areas

<100% of
within shift

Quality No error
errors

Quality No error
Completed Health
errors

Quality Incomplete
error
error. error.
errors
error. error.
errors
I, MS. CRESENCIA F MENDOZA RM II, of the Pediatric Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in accordance
with the indicated measures for the period July to December, 2015.
_______________________
Employee
Date: ___________________
CPT VICTORIA B DE ROCAS NC LTC DENNIS R FERRER NC

Rating
Ql1 Qn2 T3 A4
Core Function
Vital Signs / I&O 100% of patients, within the shift, with zero (0)
100% of patients, within the shift or with 2-3 errors. 3 3 3 3

Reporting Deficiency <100% of patients, within the shift or with 4-5 errors. 2 2 2 2
error
Record
Pediatric Assessment 100% of patients, within the shift, with zero (0)
100% of patients, within the shift or with 2-3 errors. 3 3 3 3
Midwife Procedures
100% of patients within shift with 0 (zero) error. 100% of patients within shift with 2 errors. 3 3 3 3
Deficiency Record
Proactive involvement
on Child Life Program
Pediatric Growth and 100% of conducted relevant Integrated Pediatric 100% of conducted relevant Integrated Pediatric
and Kythe Foundation
Development Program Growth and Development Programs reported on Growth and Development Programs reported on or 5 5 5 5
activities as well as on
Reports or before deadline before deadline
the conduct of School
Readiness Program
Health Teaching Record 100% of patients within shift with 0 (zero) error. 100% of patients within shift with 1 error. 4 4 4 4
Support Function
Housekeeping complied
NAP 5S Deficiency 100% of all assigned areas within shift with 0 but needs to clear
<100% of all assigned areas within shift with 8 errors. 1 1 1 1
Record (zero) error. clinical area before
endorsement
Clinical Area
Clinical Area disorganized and
Equipment / Supply <100% of supply/Equipment within shift with 6 errors. 1 1 1 1 supplies not properly
(zero) error.
Record labeled and placed on
proper container
Needs improvement on
reporting and recording
100% of patients within shift with 0 (zero) error. <100% of patients, after the shift with 6 errors 1 1 1 1 of childhood illnesses
Deficiency Record
and pediatric ward
prevalent cases
Research / HRDP - Complete requirements, Excellent substance, on Complete requirements, Excellent substance, on or
5 5 5 5 Very relevant
COPAR or before deadline with 0-1 error. before deadline with 0-1 error.


MS. CRESENCIA F MENDOZA RM II CPT VICTORIA B DE ROCAS NC LTC DENNIS R FERRER NC


_____________________________________________
________Registered Midwiife I SG- 9________
___________Clinical Care Branch - Obstetrics and Gynecology Ward (OBGYN)_______


Quality accurate
Timeliness within shift 100% of patients, within 100% of patients, within <100% of patients, within
monitors and records 100% of patients, within 100% of patients, within <100% of patients, within
accurate patient data the shift, or with 1 error. the shift or with 2-3 errors. the shift or with 4-5 errors.
Quantity all patients error error more errors.
2. NAP Deficiency in Reporting Critical Patient Data Record

Quality No error
errors
4. Labor Monitoring Sheet
Quality accurate
progress of patient Timeliness within shift the shift, with zero (0) the shift, with zero (0) the shift or with 6 or
labor error error more errors.

Quality No error
Completed EINC Timeliness completed within shift 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within
Procedure Checklist shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
errors

Quality No error
Accomplished 5s
Timeliness completed within shift 100% of all assigned 100% of all assigned 100% of all assigned 100% of all assigned <100% of all assigned <100% of all assigned
standard at all
areas within shift with 0 areas within shift with 0 areas within shift with 1 areas within shift with 2 areas within shift with 3 areas within shift with 4
assigned areas within
the shift Quantity all assigned areas

Quality No error
Complete accounting <100% of
100% of 100% of supply/Equipment 100% of <100% of
of nursing Timeliness within shift 100% of supply/Equipment supply/Equipment within
supply/Equipment within within shift with 0 (zero) supply/Equipment within supply/Equipment within
supply/Equipment within shift with 1 error. shift with 6 or more
shift with 0 (zero) error. error. shift with 2 errors. shift with 3 errors.
within shift errors.
Quantity all equipment and supply

Quality No error
Completed Health
Teaching Protocol of Timeliness completed within shift 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within
all patients upon shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
errors
I, MS. LORENA P CRUZ RM I, of the Obstetrics and Gynecology Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in
_______________________
Employee
Date: ___________________

CPT GRACE MARIE N SANTOS NC LTC JAMES PAUL C DEL ROSARIO NC
Rating
Ql1 Qn2 T3 A4
Core Function
100% of patients, within the shift or with 2 errors. 3 3 3 3
NAP Deficiency in
Reporting Critical 100% of patients, within the shift or with 3 errors. 3 3 3 3
error
Patient Data Record
Midwife Procedures
100% of patients within shift with 0 (zero) error. 100% of patients within shift, with 3 errors. 3 3 3 3
Deficiency Record

Labor Monitoring Sheet 100% of patients, within the shift or with 2 errors. 3 3 3 3
error
EINC Procedure
Checklist Deficiency 100% of patients within shift with 0 (zero) error. 100% of patients, within the shift, or with 1 error. 4 4 4 4
Record
Health Teaching Record 100% of patients within shift with 0 (zero) error. 100% of patients, within the shift, or with 1 error. 4 4 4 4
Support Function
100% of all assigned areas within shift with 2 error. 3 3 3 3
Clinical Area
Equipment/Supply 100% of supply/Equipment within shift with 2 errors. 3 3 3 3
(zero) error.
Record

LTC JAMES PAUL C DEL

MS. LORENA P CRUZ RM I CPT GRACE MARIE N SANTOS NC
ROSARIO NC

_____________________________________________
________Registered Midwiife I SG-9________
___________Clinical Care Branch - Neonatal Intensive Care Unit (NICU)____


Quality accurate
Quality accurate
3. Neonatal Assessment Deficiency Record
Quality accurate

Quality No error
errors

Quality No error
Checklist errors

Quality No error
Accomplished 5s
assigned areas

<100% of
within shift

Quality No error
Completed Health
errors
I, MS. CRISTINA C VALENCIANO RM I, of the Neonatal Intensive Care Unit, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in
_______________________
Employee
Date: ___________________

CPT CHRISTIAN RAEGAN L IGNACIO NC LTC MARIA AURORA O TORRES NC
Rating
Ql1 Qn2 T3 A4
Core Function

Reporting Deficiency 100% of patients, within the shift or with 2 errors. 3 3 3 3
error
Record
Neonatal Assessment 100% of patients, within the shift, with zero (0)
Midwife Procedures
100% of patients within shift with 0 (zero) error. 100% of patients within shift, with 2 errors. 3 3 3 3
Deficiency Record
EINC Procedure
Checklist Deficiency 100% of patients within shift with 0 (zero) error. 100% of patients within shift, with 3 errors. 3 3 3 3
Record
Health Teaching Record 100% of patients within shift with 0 (zero) error. 100% of patients within shift, with 3 errors. 3 3 3 3
Support Function
Clinical Area
Equipment/Supply 100% of supply/Equipment within shift with 2 errors. 3 3 3 3
(zero) error.
Record

MS. CRISTINA C VALENCIANO RM I CPT CHRISTIAN RAEGAN L IGNACIO NC LTC MARIA AURORA O TORRES NC

_____________________________________________
________Registered Midwiife I SG-9_______
___________Clinical Care Branch - Pediatric Ward (W6C)_____


Quality accurate
Quality accurate
3. Pediatric Assessment Deficiency Record
Quality accurate

Quality No error
errors

Quality No error
Accomplished 5s
assigned areas

<100% of
within shift

Quality No error
errors

Quality No error
Completed Health
errors
I, MS. MARIA CONSOLACION D RODRIGUEZ RM I, of the Pediatric Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets
in accordance with the indicated measures for the period July to December, 2015.
_______________________
Employee
Date: ___________________

CPT CARLITO D RENANTE NC MAJ TROY KELLY F DUMAMPILIS NC
Rating
Ql1 Qn2 T3 A4
Core Function
100% of patients, within the shift, or with 1 error. 4 4 4 4

Reporting Deficiency 100% of patients, within the shift, or with 1 error. 4 4 4 4
error
Record
Pediatric Assessment 100% of patients, within the shift, with zero (0)
100% of patients, within the shift, or with 1 error. 4 4 4 4
Midwife Procedures
100% of patients within shift with 0 (zero) error. 100% of patients, within the shift, or with 1 error. 4 4 4 4
Deficiency Record
Health Teaching Record 100% of patients within shift with 0 (zero) error. <100% of patients, within shift with 10 errors 1 1 1 1
Support Function
Clinical Area
100% of supply/equipment within shift with 0
Equipment/Supply 100% of supply/equipment within shift with 1 error. 4 4 4 4
(zero) error.
Record
100% of patients within shift with 0 (zero) error. 100% of patients within shift with 1 error. 4 4 4 4
Deficiency Record

Overall Equivalent Adjectival Rating Very Staisfactory

MAJ TROY KELLY F DUMAMPILIS

MS. MARIA CONSOLACION D RODRIGUEZ RM I CPT CARLITO D RENANTE NC
NC

_____________________________________________
________Nursing Attendant II SG-6________
___________Clinical Care Branch - Dermatology Ward (W6D)________


monitors and Quality accurate 100% of patients, within 100% of patients, within <100% of patients, within
records accurate Timeliness within shift the shift, with zero (0) the shift, with zero (0) the shift or with 6 or
3. Delegated Nursing Procedure Deficiency Record
Quality No error
Completed <100% of patients, within
delegated nursing Timeliness completed within shift shift with 6 or more
procedure errors
Accomplished 5s Quality No error

standard at all
Timeliness completed within shift areas within shift with 0 areas within shift with 0 areas within shift with 1 areas within shift with 2 areas within shift with 3 areas within shift with 4
assigned areas
5. Nursing Equipment/Supply Record

<100% of
nursing supply/Equipment within within shift with 0 (zero) supply/Equipment within supply/Equipment within
supply/equipment shift with 0 (zero) error. error. shift with 2 errors. shift with 3 errors.
within shift
6. Delegated Nursing Administrative Deficiency Record

Quality No error
Completed
100% of delegated tasks 100% of delegated tasks 100% of delegated tasks <100% of delegated
delegated nursing Timeliness completed within shift 100% of delegated tasks <100% of delegated tasks
within shift with 0 (zero) within shift with 0 (zero) within shift, with 2-3 tasks, within shift with 6
administrative within shift with 1 error. within shift with 4-5 errors
error. error. errors. or more errors
work Quantity all delegated tasks
7. NAPIC Management Deficiency Record

Quality No error
Completed
100% of delegated tasks 100% of delegated tasks 100% of delegated tasks <100% of delegated
NAPIC delegated Timeliness completed within shift 100% ofdelegated tasks <100% of delegated tasks
within shift with 0 (zero) within shift with 0 (zero) within shift, with 2-3 tasks , within shift with 6
administrative within shift with 1 error. within shift with 4-5 errors
error. error. errors. or more errors
work Quantity all delegated tasks
I, MS. MARITESS V DELA CRUZ NA II, of the Dermatology Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in
_______________________
Employee
Date: ___________________

CPT RICHARD F DELA PENA NC LTC RICARDO F SANTOS NC
Rating
Ql1 Qn2 T3 A4
Core Function
Vital signs/ I&O 100% of patients, within the shift, with zero (0) Accurately and
100% of patients, within the shift, with zero (0) error 5 5 5 5
Monitoring Sheet error competently done
NAP Deficiency in
100% of patients, within the shift, with zero (0) Well appreciated by co-
Reporting Critical 100% of patients, within the shift, with zero (0) error 5 5 5 5
error staf
Patient Data Record
Delegated Nursing
100% of delegated tasks within shift with 0 (zero) Well appreciated by co-
Procedure Deficiency 100% ofdelegated tasks within shift with 0 (zero) error. 5 5 5 5
error. staf
Record
Delegated Nursing Administrative reporting

100% of delegated tasks within shift with 0 (zero) 100% of delegated tasks within shift with 0 (zero)
Administrative 5 5 5 5 well organized and
error. error.
Deficiency Record complete
Support Function
NAP 5S Deficiency 100% of all assigned areas within shift with 0 100% of all assigned areas within shift with 0 (zero) Clinical Area well
5 5 5 5
Record (zero) error. error. maintained and neat
Nursing Well maintained and

100% of supply/Equipment within shift with 0 100% of supply/Equipment within shift with 0 (zero)
Equipment/Supply 5 5 5 5 Stock Cards are
(zero) error. error.
Record updated
NAPIC Management 100% of delegated tasks within shift with 0 (zero) 100% of delegated tasks within shift with 0 (zero)
5 5 5 5 Well organized
Deficiency Record error. error.

Intervening point score

MS. MARITESS V DELA CRUZ NA II CPT RICHARD F DELA PENA NC LTC RICARDO F SANTOS NC

_____________________________________________
________Nursing Attendant I SG-4________
___________Clinical Care Branch - Dermatology and Burn Unit Ward (W6D)________


monitors and Quality accurate 100% of patients, within 100% of patients, within <100% of patients, within
records accurate Timeliness within shift the shift, with zero (0) the shift, with zero (0) the shift or with 6 or
3. Delegated Nursing Procedure Deficiency Record
Quality No error
Completed <100% of patients, within
delegated nursing Timeliness completed within shift shift with 6 or more
procedure errors
Accomplished 5s Quality No error

standard at all
Timeliness completed within shift areas within shift with 0 areas within shift with 0 areas within shift with 1 areas within shift with 2 areas within shift with 3 areas within shift with 4
assigned areas
5. Nursing Equipment/Supply Record

<100% of
nursing supply/Equipment within within shift with 0 (zero) supply/Equipment within supply/Equipment within
supply/equipment shift with 0 (zero) error. error. shift with 2 errors. shift with 3 errors.
within shift
6. Delegated Nursing Administrative Deficiency Record

Quality No error
Completed
delegated nursing Timeliness completed within shift 100% of patients within 100% of patients within 100% of patients within 100% of patients within <100% of patients within
administrative shift with 0 (zero) error. shift with 0 (zero) error. shift with 1 error. shift, with 2-3 errors. shift with 4-5 errors
errors
work Quantity all patients
I, MS. MARICRIS A DELA RUIZ NA I, of the Dermatology and Burn Ward, Division of Nursing commit to deliver and agree to be rated on the attainment of the following targets in
_______________________
Employee
Date: ___________________

CPT GERARD T DE MESA NC LTC RICARDO F SANTOS NC
Rating
Ql1 Qn2 T3 A4
Core Function
100% of patients, within the shift, with zero (0) error 5 5 5 5 Well Organized
NAP Deficiency in
Reporting Critical 100% of patients, within the shift, with zero (0) error 5 5 5 5 Systematic
error
Patient Data Record
Delegated Nursing
100% of delegated tasks within shift with 0 (zero) 100% of delegated tasks within shift with 0 (zero) Well Appreciated by co-
Procedure Deficiency 5 5 5 5
error. error. staff
Record
Delegated Nursing
100% of delegated tasks within shift with 0 (zero) 100% of delegated tasks within shift with 0 (zero) Well Appreciated by co-
Administrative 5 5 5 5
error. error. staff
Deficiency Record
Support Function
NAP 5S Deficiency 100% of all assigned areas within shift with 0 100% of all assigned areas within shift with 0 (zero)
5 5 5 5 Well Maintained
Record (zero) error. error.
Nursing
100% of supply/Equipment within shift with 0 100% of supply/Equipment within shift with 0 (zero)
Equipment/Supply 5 5 5 5 Well Maintained
(zero) error. error.
Record

MS. MARICRIS A DELA RUIZ NA I CPT GERARD T DE MESA NC LTC RICARDO F SANTOS NC

(FORM F)
Daily Individual Work Output Journal

________________(Office)_________________
__________________(Name)__________________ DATE:
__________________(Position/SG)__________________
__________________(Division)__________________
Div Time Revision

Output Subject Output Quality Quantity Remarks
Assigned Accomplished No.
ID No.
Prepared by: Noted by:
Employee's Name and Signature Supervisor's Name and Signature

Weekly Consolidated Individual Work Output Table
________________(Office)_________________
PERIOD COVERED:
__________________(Name)__________________
_________________(Position/SG)_________________
__________________(Division)__________________
Div Maximum No. of

Output Date Output Time Quality Quantity Remarks
Revisions
ID No. Completed
Supervisor's Comments:
Prepared by: Reviewed / Noted by:
Employee's Name and Signature Supervisor's Name and Signature
Date: ________________ Date: _________________

(FORM H)
Performance Monitoring and Coaching Journal
1st
2nd
Quarter
3rd
4th
Name of Division _________________________________
Division Chief ___________________________________
Number of Personnel in the Division _______________
Mechanisms
Activity Meeting Remarks
Memo Others (Pls. Specify)
One-on-One Group
Monitoring
Coaching
Please indicate the date in the appropriate box when the monitoring was conducted.
Conducted by: Date: Noted by: Date:
Immediate Superior Head of Office

(Form I)
Sample Summary List of Individual Performance Rating
Office A Performance Assessment: Very Satisfactory
Rating
Division A
Numerical Adjectival
Division A Rating
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
No. of Employees = 5
Average ratings of staff
Rating
Division B
Division B Rating
Employee 1
Employee 2
Employee 3
Employee 4
Rating
Division C
Division C Rating
Employee 1
Employee 2
Employee 3
Employee 4
Summary:
Division A 4 Very Satisfactory
Division B 3 Satisfactory
Division C 5 Outstanding
Average 12/3= 4 Very Satisfactory
Performance Rewarding and Development
Professional Development Plan

Date:
Target Date
Review Date
Achieved Date
Aim
Objective
Task Next Step
Comments
Discussed with: Date: Prepared by: Date:
Employee Supervisor
(Form J)
Development
Next Step
Approved by: Date:
Head of Office

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Office Performance Output Table

Quantity 3 Integrity Development Policies developed 3 Integrity Development Policies developed

OFFICE PERFORMANCE COMMITMENT AND REVIEW (OPCR)

Reviewed by Date Confirmed by Date

LTC ANTONIO G PUNZALAN MC (GSC) COLONEL EDWIN LEO T TORRELAVEGA MC (GSC)

Approved by* Date

COLONEL SANTIAGO I ENGINCO PA (GSC)

SUCCESS INDICATORS (TARGETS + Actual Rating

70% of all personnel action request accomplished

70% of all the Nursing Personnel disciplinary

100% of All Issued Supplies for 24 hours are

100% of all Nursing Personnel's attendance and

90% of approved schedule of ALL clinical areas

70% of RN Residents will pass the program

70% of the RLE exposures of nursing students Education and Training

70% of P2LTs will pass the Course requirements

70% of students will pass the Course

70% of Nursing Personnel should attend at least

70% of Clinical Areas satisfactorily presented case Education and Training

70% of Nursing Personnel satisfactorily passed

All sentinel events are Collected, Analyzed, and

70% of Nurses satisfactorily participate in

CORE FUNCTION MFO 1: Quality nursing care services

Assessed by: Confirmed by: Final Rating by: Date

Legend: 1 - Quality (Ql) 2 - Quantity (Qn) 3 - Timeliness (T) 4 - Average (A)

2LT NOVIE CARLA G PAGADUAN NC

Mr Claresto Rhuir Bas-awan RN I

Ms Mary Rose Regaspi NA

11 & above notices of loafing 6 - 10 notices of 5 notices of loafing

Tasked as member of Technical

Performed > 16 hours cumulative

PERFORMANCE SUCCESS INDICATOR PERFORMANCE STANDARDS

11. Nurse Manager Role Deficiency Checklist

12. Assistive Nurse Manager Deficiency Record

Reviewed by Date Approved by Date

CPT KRISTINA L SALVADOR NC LTC CAROLINE D COMMENDADOR NC

100% of patients, within 24 hours with 0 (zero)

10Rs correctly observed and

ISOBAR Deficiency Disorganized, Incomplete,

Emergency Cart 100% of Emergency Cart Equipment within shift

Discussed with Date Assessed by Date Final Rating by Date

CPT KRISTINA L SALVADOR NC LTC CAROLINE D COMMENDADOR NC

Legend: 1 - Quality (Ql) 2 - Quantity (Qn) 3 - Timeliness (T) 4 - Average (A)

PERFORMANCE SUCCESS INDICATOR PERFORMANCE STANDARDS

6. Health Teaching Record

7. Nursing Progress Notes

9. Emergency Cart Equipment Record

10. Case Study/Research Paper

Formulate/ Quality 0 error in format/substance

checks NCP Quality 0 error

Reviewed by Date Approved by Date

CPT KARLA MINA N DELA ROSA NC LTC CAROLINE D COMMENDADOR NC

100% of patients, within 24 hours with 0 (zero) Incomplete and unfilled up

NCP Template / Clinical

Insufficient and incomplete

Average point score 3.08 3.08 3.08 3.08

Discussed with Date Assessed by Date Final Rating by Date

CPT KARLA MINA N DELA ROSA NC LTC CAROLINE D COMMENDADOR NC

Legend: 1 - Quality (Ql) 2 - Quantity (Qn) 3 - Timeliness (T) 4 - Average (A)

2. Patient Assessment Progress Notes

Quality No errors in Standard Protocols

3. Nursing Care Plan

5. Nursing Procedures Defficiency Monitoring Record