INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR)

I, KING HAROLD G. BAUTISTA, Nurse I (Outpatient Department ) of the NUEVA VIZCAYA PROVINCIAL HOSPITAL, Division of NURSING DEPARTMENT commit to deliver
and agree to be rated on the attainment of the following targets in accordance with the indicated measures for the period January to December 2020.

KING HAROLD G. BAUTISTA, RN

Ratee
Date: _______________________

Reviewed by: Date Approved by: Date

ARMIE H. GARCIA, RN, MSN ARLENE I. JARA, MD, MMHA

CHIEF NURSE Chief of Hospital II-NVPH
Immediate Supervisor Head of Office

5 – Outstanding
4 – Very Satisfactory
3 – Satisfactory
2 – Unsatisfactory
1 – Poor

Rating
MFO/PAP SUCCESS INDICATORS
(TARGETS + MEASURES) Q E T MOV

Strategic Priority
1. Patient Management All patients with 1. Correct data 5 = 100% of demands Response Time: Patient’s
Services complete, correct 2. Correct VS 1st come, 1st serve & record
CA1. Nursing Assessment comprehensive history 3. Comprehensive Hx taking order of priority
 Data gathering (personal taking & assessment in 5 4. Appropriate assessment
information, vital signs, minutes 5. Proper handling 5 = order of priority &
chief complaints ,medical 5 = all 3 = 1-4 w/in 5 min.
history 2 = >3 3 = w/in 10 min.
2 = more than 10 min.
CA2. Nursing Management
S1. Carry out doctor’s order
S2. Give medications
 IV/IM medications
S3. Performs direct patients care
a. Assist physician in the
treatment and
procedures
 Minor surgery
 Physical examination
(internal & external)
CA 3. Hospital Based Health
Education
 health teachings
CA 4. Community Outreach
 Medical Surgical Mission
 Health Education
General Administrative
Support Services
All doctor’s order carried out
accurately and completely
immediately upon order;
feedback adverse reaction (if
applicable), completed within
1 minute
All patients given
medications using the 10 Rs
in giving medications;
completed within 1 minute
per patient
Assist physician in the
treatment and procedures
with correct, complete,
ensure patients privacy &
proper handling
All patients and watchers
provided relevant, correct
understandable, brief and
concise health education
Invitations for outreach
programs attended and
participated
1. All orders carried out
2. TLC 5 = 100% demands Response Time:
3. Clear, correct & complete 1st come, 1st serve &
charting order of priority
4. Provides feedback immediately
to immediate supervisor 5 = order of priority &
5. Appropriate NCP w/in 5 min.
6. Positive feedback ROD & 3 = w/in 10 min.
patients 2 = more than 10 min.
5 = all
3 = except 4
2 = no TLC
5 = all patients given medications using 5 = 100% demands
the 10 Rs in giving medication; 5 = 1 full minute
personally administered oral 1 = less than I minute
medications to patients
3 = all patients given medications using
10 Rs in giving medications
1 = 10 Rs in giving medications not
followed
5 = correct, complete, privacy & proper 5 = all patients 5= 10 minutes
handling, no adverse feedback 3 = 15 minutes
3= correct, complete, ensure patients
privacy & proper handling
1= w/ adverse feedback
5= relevant, correct, understandable, 5= 5 minutes
brief and concise health education 5 = all patients and instructions/patient
3= relevant, correct understandable, watchers 3= 3 minutes
health education instructions /patient
1= incorrect, not understandable 1= 1 minute
instruction/patient
5 = medical/surgical/dental missions 5 = 3 per semester 5 = fully participated
participated with individual health 4 = 2 per semester (turnaround time is
instructions and documentations 3 = per semester based on the duration)
1 = refused to attend 3 = not fully
participated
1 = attendance only
1. Personnel Management
CA1. Capability Building
S1. General Staff
meeting/Section meetings
attended
S2. Trainings/ seminars/ 100%
workshops/ conferences trainings/seminars/conferenc
attended
S3. Attendance to inter agency
activities (usually hospitals)
Development of high level of
competence in basic skills
90% of scheduled 5 = 97-100% of staff/section meetings 5 =100% of meetings Minutes
general/section staff attended in full attended
meetings attended in full; as 4 = 95-96% of staff/section meetings 4 = 95% of meetings attendance
scheduled attended in full attended
3 = 90-94% of staff/section meetings 2 = 85% of meetings
attended in full attended
2 = 85-89% of staff/section meetings 1 = 80% and below
attended in full
1 = 84% and below staff/section
meetings attended in full
of endorsed TRAININGS/SEMINARS 5 = 100% of approved
training/seminars/confer 5 = report submitted 3 Post training
es/conventions attended as 5 = 97 to 100% with re-entry plan ences /workshops days after attendance report
scheduled with post implemented and approved attended 4 = report submitted 4
training/activity report and/or 4 = 95 t0 96% with re-entry plan days after attendance Post activity
re-entry plan submitted 5 implemented and approved 4 = 95% 3 = report submitted 5 report
days after training 3 = 90 to 94% with re-entry plan days after attendance
implemented and approved 3 = 90% 1 = report submitted 7 Re-entry plan
2 = 85 to 89% with reentry plan days after attendance
implemented and approved 1 = < 90% Actual output
1 = 84% and below with re-entry plan required as a
implemented and approved result of the
workshop
100% of inter-agency 5 = inter-agency activities participated; 5 = 100% inter-agency
activities participated as documented activities 3 = as scheduled
scheduled; documented; 3 = inter-agency activities attended 3 = 1 activity not
attended, non-
attendance justified

S4. Attendance to 100% of mandated/special 5 = 97 to 100% attended in full, re- 5 = 97 to 100% Re-echoed
mandated/special committee committee meetings echoed, participated mandated/special 5 = immediately upon Attendance/re
meetings attended as scheduled; re- 4 = 95 to 96% attended in full, re- committee meetings assumption to work port
echoed echoed, participated attended 4 = within 1 day
3 = 90 to 94% attended in full, re – 4 = less 1 meeting not 3 = within 5 days
echoed, participated attended but with 1 = more than 5 days
2 = 85 to 89% attended in full, re- representative sent to
echoed, participated attend
1 = 84% and below attended in full, re – 3 = less 1 meeting not
echoed, participated attended, no
representative sent to
 attend

CA2. Submission of Required Compliance in the

HR documents submission of required HR
documents
S1. Submission of PDS PDS submitted on set 5 = PDS submitted, complete, accurate 5 = 100% of PDS 5 = submitted 5 days Receiving
deadline, complete, accurate and neat, no revisions and approved on submitted before deadline copies of PDS
and neat first submission 3 = 99% submitted 4 = 3 days before
3 = PDS submitted, complete, accurate, 1 = no submission deadline
returned once by AO for deficiencies 3 = on set deadline
1 = returned 2x and more by AO for the 1 = after deadline
same deficiencies
S2. Submission of DTR 100% of DTRs submitted on 5 = 12/12 DTR submitted, complete, DTRs submitted to the Deadline of
set deadline, complete, accurate and neat, no revisions and 5 = 100% DTRs AO submission to
accurate and neat approved on first submission 5 = 5 days before the AO: on the
4 = 10/12 DTR submitted, complete, 1 = 99% and below deadline 5th day of the
accurate and neat, no revisions and 4 = 3 days before following
approved on first submission deadline month
3 = 8/12 DTR submitted, complete, 3 = on set deadline
accurate, returned once by AO for 1 = 2 days after
deficiencies deadline
2 = 4/12 DTR submitted, complete,
accurate and neat, no revisions and
approved on first submission
1 = 2/12 DTR submitted, complete,
accurate and neat, no revisions and
approved on first submission
S3. Submission of SALN SALN submitted on set 5 = SALN submitted, complete, 5 = 1 SALN submitted 5 = 5 days before
deadline, complete, accurate accurate and neat, no revisions and 1 = not submitted deadline
and neat approved on first submission 4 = 3 days before
3 = SALN submitted, complete, deadline
accurate, returned once by AO for 3 = on set deadline
deficiencies 1 = after deadline
1 = returned 2x and more by AO for the
same deficiencies
S4. IPCRs (Targets) prepared 1 IPCR (targets) prepared 5 = prepared as to prescribed format 5 = 1 IPCR (targets) 5 = submitted to the
and submitted as to prescribed format and and approved OPCR, complete as to prepared and submitted DC/SC for review on
approved submitted to assigned targets, duly signed, received 1 = no IPCR (targets) Dec 5/ June 5 receiving
concerned official for review by admin and properly routed to DH for prepared 3 = submitted Dec copies
on set deadline review, no revisions upon 1st 7/ June 7
submission 2 = submitted Dec
3 = prepared as to prescribed format 10/ June 10

S5. IPCRs (Ratings) prepared 1 IPCR (ratings) prepared
and submitted as to prescribed format and
approved OPCR (targets)
and submitted to concerned
official for review on the 5th
day of July and 5th day of
January of the ensuing year
and approved OPCR, duly signed, 1 = submitted beyond
received by admin and properly routed December 10/ June
to DH for review, not all assigned 10
targets are reflected, with revisions
1 = not in prescribed form, not in
accordance with OPCR assigned
targets
5 = prepared as to prescribed format; 5 = 1 IPCR (ratings) 5 = submitted to the
neat, complete as to content (as per prepared and submitted DC/SC for review Jan receiving
approved targets and as per 1 = no IPCR (ratings) 5/July 5 copies
accomplishment), duly signed; received prepared 3 = submitted Jan
by admin and properly routed to 7/July 7
Division Head for review; complete 2 = submitted Jan
MOVs attached 10/July 10
3 = prepared as to prescribed format; 1 = submitted
complete as to content (as per beyond Jan 10/July 10
approved targets and as per
accomplishment), duly signed; received
by admin and properly routed to
Division Head for review; MOVs
attached not complete
1 = not in accordance with prescribed
format, incomplete and inaccurate

2. Records Management All clinical records correct, 5 = records are properly stored, readily
S1. Records filedand complete and accounted available, good condition, 5 = 100% of records 3 = tour of duty
maintained coded/classified, complete and in maintained
> OPD logbook prescribed format 1 = missing logbook
> Consultation logbook 4 = records are properly stored, readily
> Minor OR logbook available, good condition,
> CF4 encoded coded/classified and complete
3 = records are properly stored, readily
available, classified and coded
1 = records are incomplete and not
readily available
4. Supply and Equipment Supplies and equipment 5 = buffer stock maintained
Management available when needed; 4 = supplies and equipment always 5 = all supplies 3 = tour of duty
S1. Inventory buffer stock maintained for available for use
conducted/supervised six months and shortage 3 = shortage remedied/not felt
 Determine the need for remedied/not felt; as per 2 = shortage not remedied
supplies and equipment PPMP 1 = shortage perennial and not
based upon past remedied
 experience and future
plans for program of
patient care.
 Make proper
representation to the
administration of the
need of the department
 Coordinate with
maintenance and
property section to meet
the needs for supplies
and equipment for the
nursing service
S2. Periodic Checking and All equipment are in good Equipment checked for damages (C), 5 = all equipment 5 = monthly
Maintenance operating condition at all Standard maintenance work performed exclusively/personally 4 = quarterly
 Timely reporting of un- times; equipment checked (M), Finding reported (F), No Downtime used 1 = semi-annually
Serviceable/lost for damages (c), Standard (N)
instrument/equipment. Maintenance work
 Reinforced proper performed (M), Findings 5 = CFMN
endorsements reported (F), No Downtime 3 = CFM
 Disposal of (N) 1 = Not C/F/M
unserviceable
equipment.
Care & maintenance of all
equipment
4. Clean and Green General cleanliness and 3 = tour of duty
S1. Observe 5 “S” of orderliness of work area
3 = work area
housekeeping maintained 5 = well-organized
 Sorting 3 = odor free, dust free, clean
 Systematized 1 = disorganized
 Standardized
 Sweep
 Self-discipline
5. Waste Management All hospital wastes properly 5 = proper segregation 3 = tour of duty
Direct the implementation of segregated, collected and 1 = wastes not properly segregated 5 = all wastes
proper disposal of all hospital disposed
wastes