HEADQUARTERS

ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

V LUNA MEDICAL CENTER
Camp Colonel Victoriano K. Luna, V. Luna Rd., Quezon City
PERFORMANCE EVALUATION REPORT FORM
01 Jan 2018 to 30 June 2018

EMPLOYEE: ______________________ OFFICE: V. Luna Medical Center

POSITION: ______________________ DIVISION/SECTION: Nursing Service

Part 1 – Performance (70%)

Quantity Quality Time Rating
Duties and Responsibilities Remarks
Planned Actual Planned Actual Planned Actual Q1 Q2 T
Plan and organize posting of NS 3 missed Every
all All No error Every month 5 5 5
personnel in the clinical area personnel 2months
Assess implementation of nursing
2 missed
procedures, protocols and policies 2 wards 5 wards No error 4 weeks Every day 5 5 5
wards
that govern the nursing practice
Serves as change agent and support With
With 1 hour, 30
nursing staff during times of difficult 1 staff 2 staff compassion 30 mins 5 4 5
compassion min
transition
Facilitates meeting with case
3 missed Complete
managers to enforce in developing 1 meeting 1 meeting 5 hours 4 hours 5 4 5
data data
patient focused management plan.
Consolidates and evaluates
28 case 28 case
performance output of case 1 error No error 2 days later On time 4 5 5
managers manager
managers/submits reports
Participates in the formulation,
revision and implementation of 3 missed No missed
5 5 monthly monthly 4 5 4
healthcare policies and standards of data data
practice
Assist in the implementation of
quality improvement program of the Complete
2 wards 3-4 wards 1-2 errors quarterly Everyday 4.7 5 5
service based from nursing audit data
results
Checks/process leave applications/
Accurate
absences of civilian nursing 85% 100% 1 error 2 hours 45mins 5 4.7 5
(no error)
personnel
TOTAL
Grand Total
Average
Point Score
 Equivalent
Point Score

I agree to achieved these targets for the rating period of

01 January to 30 June 2018

----------------------------------------------------------------------------------
 INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR)
FORM E

I, ______________________________, of the CLINICAL BRANCH, DIVISION OF NURSING commit to deliver and agree to be rated on the attainments of the following of
targets in accordance with the indicated measures for the period from 01January to 30 June 2018.

_________________
Employee

Date: _____________

Reviewed by: Date Approved by: Date

Immediate Supervisor Head of Office

Rating
Output Success Indicator (Target + Measure) Actual Accomplishments REMARKS
Q1 Q2 T3 A4
Core Plan and organize posting of all NS personnel in Planned and organized posting of all NS personnel in the
Function the clinical area every 2 months with 3 missed clinical area every month without error
personnel
Assess implementation of 2 nursing procedures, Assessed implementation of nursing procedures, protocols
all protocols and policies that govern the nursing and policies that govern the nursing practice every 2 weeks
practice every month with 2 miss wards accurately
Serves as change agent and support 1 nursing Served as change agent and support 2 nursing staff for 1
staff for 1 hour and 30 minutes with compassion hour with compassion during times of difficult transitions
during times of difficult transitions
Facilitates 1 meeting with case manager for 5
Facilitated 1 meeting for case managers 6 hours every
hours monthly with case managers to enforce in
month to enforce in developing patient focused
developing patient focused management plan
Case management plan.
with 3 missed data.
Management
Consolidates and evaluates performance output
Consolidated and evaluated performance output of 30 case
of 28 case managers, submitted 2 days later
managers, submitted reports 3 days before deadline
after deadline with one error
Participates in the formulation, revision and
Participated in the formulation, revision and implementation
implementation of 5 healthcare policies and
of 5 healthcare policies and standards of practice in a
Nursing Policy standards of practice in a month with 3 missed
month with no missed data
Related Functions data
Participates in conducting nursing audit 2 wards Participated in conducting nursing audit 3-4 wards every
every day in every quarter with 2-3 errors day in every quarter with no errors
Checks/process 85% of leave applications of
Checked/processed 100% of leave application of civilian
Support Function civilian nursing personnel within 2 hours with 1
nursing personnel within 45 minutes accurately.
error
 Overall point score
Intervening point score
Overall Equivalent Numerical Rating
Overall Equivalent Adjectival Rating
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

CAPT GRACE A INFANTE PN (MNSA)

Employee Supervisor Head of Office

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

 Individual Work Output Table
Office of the Nursing Service
REMEDIOS C. OLANO RN II
Nurse II – SG-15 (Chief, Case Management)
SUCCESS
Major Final PERFORMANCE PERFORMAN
MEASURES CE TARGET
INDICATOR PERFORMANCE STANDARDS
Output Measures + Targets
Outstanding Very Satisfactory Satisfactory Unsatisfactory Poor
Plan and Quality 3 missed Planned and organized Planned and organized Planned and organized Planned and organized Planned and organized Planned and organized
organize posting of personnel posting of all NS posting of all NS posting of all NS posting of all NS posting of all NS posting of all NS
NS personnel in the Timelines Every 2 mos personnel in the clinical personnel in the clinical personnel in the clinical personnel in the clinical personnel in the clinical personnel in the clinical
clinical area area every 2mos with 3 area every month area every month with area every two months area every quarter with area semi-annually with
Quantity All missed personnel without error 2 missed personnel with 3 missed personnel 3 missed personnel 3 missed personnel

Assess Quality 2 missed wards Assessed Assessed Assessed Assessed Assessed Assessed
implementation of implementation of 2 implementation of 5 implementation of 4 implementation of 2 implementation of 2 implementation of 2
nursing procedures, nursing procedures, all nursing procedures, all nursing procedures, all nursing procedures, all nursing procedures, all nursing procedures, all
protocols and Timelines Every week protocols and policies protocols and policies protocols and policies protocols and policies protocols and policies protocols and policies
policies that govern that govern the nursing that govern the nursing that govern the nursing that govern the nursing that govern the nursing that govern the nursing
the nursing practice Quantity practice every month practice every day to all practice every other practice every week practice every week with practice every week with
with 2 missed wards wards day to all wards with 2 missed wards 3-4 missed wards 4 missed wards
4 wards with
Serves as change Quality compassion Served as change agent Served as change Served as change Served as change agent Served as change agent Served as change agent
agent and support and supported 1 nursing agent and supported 2 agent and supported 2 and supported 1 staff and supported 1 staff for and supported 1 staff for
staff during times of Timelines 1 hour 30 min staff for 1 hour and 30 staff for 30 min with staff for 1 hour with for 1 hour 30 min with 2 hours with compassion 2 hours and 30 min with
difficult transitions min with compassion compassion during compassion during compassion during during times of difficult compassion during times
during times of difficult times of difficult times of difficult times of difficult transitions of difficult transition
Quantity 1 staff transitions transitions transitions transitions

Facilitates Quality 3 missed data Facilitates 1 meeting with Facilitated 1 meeting Facilitated 1 meeting Facilitated 1 meeting Facilitated 1 meeting Facilitated 1 meeting with
meeting with case case managers, 3 missed with case managers with case manager, 2 with case managers, for with case managers for case managers for 8
managers to enforce Timeliness 5 hours data for 5 hours monthly (complete attendance) absent for 4 hours 5 hours monthly to 6 hours monthly to hours monthly to enforce
in developing patient to enforce in developing for 4 hours monthly to monthly to enforce in enforce in developing enforce in developing in developing patient
focused Quantity 1 meeting patient focused enforce in developing developing patient patient focused patient focused focused management
management plan. management plan. patient focused focused management management plan with 3 management plan with 2 plan with 2-3 missed data
management plan with with 2 missed data. missed data missed data
complete data.
Consolidates and
evaluates
Quality 1 error Consolidated and
evaluated performance
Consolidated and
evaluated performance
Consolidated and
evaluated performance
Consolidated and
evaluated performance Consolidated Consolidates and
evaluated performance
performance output output of 28 case output of 28 case output of 28 case output of 28 case and evaluated output of 28 case
Timeliness 2 days later performance output of
of case managers, submitted 2 managers, submitted managers, submitted managers, submitted 2 managers submitted
managers/submits days later after deadline reports on time with no reports 1 day later after days later after deadline 28 case managers reports 3 days later with 2
Quantity 28 case submitted reports 2
reports with one error. error deadline with 1 error with 1 error. errors.
managers days later with 2 errors
Participates in the Participated in the Participated in the Participated in the Participated in the Participated in the Participates in the
formulation, revision Quality 3 missed data formulation, revision and formulation, revision and formulation, revision formulation, revision and formulation, revision and formulation, revision and
and implementation implementation of 5 implementation of 5 and implementation of implementation of 5 implementation of 4 implementation of 3
of healthcare policies healthcare policies and healthcare policies and 5 healthcare policies healthcare policies and healthcare policies and healthcare policies and
and standards of standards of practice in a standards of practice in and standards of standards of practice in standards of practice in standards of practice in a
practice Timeliness monthly month with 3 missed data a month with no practice in a month a month with 3 missed a month with 3 missed month with 3 missed data
missed data with 2 missed data data data
Quantity 5
Participate in Quality Participated in Participated in Participated in Participated in Participated in Participated in
conducting nursing 1-2 errors conducting nursing audit conducting nursing audit conducting nursing conducting nursing audit conducting nursing audit conducting nursing audit
audit to all clinical 2 wards every day in 3-4 wards every day in audit 2 wards every 2 wards every day in 2 wards every day in 2 wards every day in
areas Timeliness Every quarter every quarter with 1-2 every quarter with day in every quarter every quarter with 1-2 every quarter with 2-3 every quarter with 3-4
errors complete data with complete data errors errors errors
Quantity 2 wards
 Checks/process Checked 85% leave Checked 100% leave Checked 95% leave Checked 85% leave Checked 85% leave Checked 85% leave
leave applications/ Quality 1 error applications of civilian applications of civilian applications of civilian applications of civilian applications of civilian applications of civilian
absences of civilian nursing personnel within nursing personnel within nursing personnel nursing personnel nursing personnel within nursing personnel within
nursing personnel Timeliness 2 hours 2 hours with 1 error 45 accurately within 1 hour no error within 2 hours with 1 2 hours with 2 errors 2 hours, 3-4 errors
error

Quantity 85%