IPPMS

Office Performance Output Table
OASPER
January - December 2013
STRATEGIC PRIORITY
MFO / KDP
Measures
Targets
KDP: Defense Resource Management System, Defense System of Management
1 HR / CD Plan developed
Quantity
completed before the start of the calendar year
Timeliness
DND Proper HR / CD Plan
Quality
OASPER APB
Quantity
Timeliness
Quality
100% acceptability upon 3 presentations

1 APB developed
within prescribed timeframe
CORE FUNCTION
MFO / KDP
Measures
MFO 1: Human Resource / Career Development Interventions
Quantity
Annual Training Calendar
List of Foreign and Local Training Programs
Timeliness
Quantity
1 approved list of foreign and local training programs
Timeliness
Timeliness
Quality
Quantity
Timeliness
Quality
Quantity
Local and Foreign Travels Assisted
completed before the start of every calendar year

90% achievable and workable as perceived by clients
Quantity
Trainings Conducted
1 approved training calendar per year
Quality
Quality
Training Designs
Targets
Timeliness
Quality
completed before the start of every calendar year

90% responsive to DND HRD needs as perceived by clients
17 approved training designs
completed within 3 days for simple and 5 days for complex designs
upon 2 presentations for simple and 4 presentations for complex designs
33 trainings conducted
accomplished within the approved training calendar
90% training requirements achieved
100% of local and foreign travel assisted
within 1 day for urgent / priority and 3 days for regular
upon 2 presentations for urgent / priority and 3 presentations for regular
MFO 2: Human Resource Management Interventions

Civilian Personnel Actions
Military Personnel Actions
Quantity
Timeliness
Quality
Quantity
Timeliness
Quality
100% of required personnel actions undertaken

within set deadline
within prescribed quality
100% of documents acted upon
within 3 days for priority and 5 days for regular documents
within 3 allowable revisions for both priority and regular documents
MFO 3: HR Policy / Program Design Implementation, Monitoring, and Evaluation

Quantity
90% of personnel data inputted and 100% updated
HR Information System
Timeliness
inputted within 2 days upon receipt of data
Quality
within 5% allowable error rate
MFO 4: HR Policy Review and Reformulation
Quantity
1 handbook drafted
Handbook on Military HR Laws and Policies
Timeliness
within the prescribed timeline
Quality
updated IPPMS guidelines approved
Quantity
within set deadline
Timeliness
Updated IPPMS
Quality
Quantity
Integrity Development Policies
Timeliness
GAD Policies
Quantity
Timeliness
KAPAGDAKA Policies
Quantity
Timeliness
Updated Citizen's Charter
Quantity
Timeliness
Quality
Quality
Quality
Quality

3 Integrity Development Policies developed
5 GAD Policies developed
2 KAPAGDAKA Policies developed
updated Citizen's Charter approved
within set deadline
1 HR Plan developed
HR Plan
Quantity
Timeliness
Quality
Updated GIP / OJT Guidelines
Quantity
Timeliness
updated GIP / OJT guidelines approved

within set deadline
Quality
SUPPORT FUNCTION
MFO / KDP
MFO 5: Admin and Support Services
Document Tracking System Design
Measures
Quantity
Timeliness
Quality
Office Supplies Management
90% responsiveness to clients' needs

100% requested supplies delivered
within 2 days upon request
Quality
90% acceptability of supplies delivered
Timeliness
Quality
Office Transport Operations
1 Document Tracking System designed

within set deadline
Quantity
Timeliness
Quantity
Office Financial Services
Targets
Quantity
Timeliness
100% budgeting and financial requirements acted upon

within set deadline
100% acceptability upon 2 revisions
100% of requested transport needs supplied
within specified timeframe upon request
Success Indicators
Accountable Division
1 HR / CD Plan completed before the start of the

calendar year with 100% acceptability upon 3
presentations
HRDD
1 APB developed within prescribed timeframe with 100%

acceptability upon 3 presentations
HRDD
Success Indicators
1 approved training calendar per year to be completed

before the start of every CY and 90% achievable and
workable
HRDD
1 approved list of foreign and local training programs to

be completed before the start of every CY and 90%
responsive to DND HRD needs
HRDD
17 training designs approved upon 2 presentations for

simple and 4 for complex designs to be completed within
3 days for simple and 5 days for complex designs
HRDD
33 trainings conducted and accomplished within the

approved training calendar with 90% training
requirements achieved
HRDD
100% of local and foreign travels assisted within 1 day

for urgent / priority and 3 days for regular approved upon
2 presentations for urgent / priority and 3 presentations
for regular
HRDD
undertaken 100% of required personnel actions within

set deadline and prescribed quality
CPD
100% of documents acted upon within 3 days for priority

and 5 days for regular documents with 3 allowable
revisions for both priority and regular documents
MPD
90% of personnel data inputted and 100% updated

within 2 days upon receipt of data with 5% allowable
error rate
CPD
1 handbook drafted within the prescribed timeline with

MPD
updated IPPMS guidelines approved within set deadline

with 100% acceptability upon 3 presentations
CPD
3 Integrity Development Policies developed within the

prescribed timeline with 100% acceptability upon 3
presentations
CPD
5 GAD Policies developed within the prescribed timeline

2 KAPAGDAKA Policies developed within the prescribed
timeline with 100% acceptability upon 3 presentations
MPD
updated Citizen's Charter approved within set deadline

CPD
1 HR Plan completed within the prescribed timeline with

CPD
updated GIP / OJT guidelines approved within set

deadline with 100% acceptability upon 3 presentations
HRDD
Success Indicators
1 Document Tracking System designed within set

deadline with 90% responsiveness to clients' needs
OD
100% requested supplies delivered within 2 days upon

request with 90% acceptability of supplies delivered
OD
100% budgeting and financial requirements acted upon

within set deadline with 100% acceptablity upon 2
revisions
OD
100% of requested transport needs supplied within

specified timeframe upon request
OD
(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
LTC ANTONIO G PUNZALAN MC (GSC)

Executive Officer, VLGH
Confirmed by
Date
COLONEL EDWIN LEO T TORRELAVEGA MC (GSC)

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
MFO/PAP
SUCCESS INDICATORS (TARGETS + MEASURES)
Allotted Budget
Division Accountable
STRATEGIC PRIORITY
To provide tertiary health care services
5426 patients treated per semester
VLGH
85% Level of Satisfaction of all patients towards nurses per month
NSD
70% Average Score from the Level of Satisfaction of All Nursing

Personnel at the end of the year
Clinical Br
70% of all personnel action request accomplished within (3)

working days
Admin Br
Personnel Appraisal
70% of All Personnel appraisal is accomplished and submitted with 0

errors in format within one month after the rating period
Admin Br
Personnel Discipline
70% of all the Nursing Personnel disciplinary actions monitored

and recorded per month
Clinical Br
Sterile Supplies Processing
100% of All Issued Supplies for 24 hours are Sterile
CSR
Attendance and Punctuality
100% of all Nursing Personnel's attendance and punctuality will

be recorded and monitored per month
Clinical Br
90% of approved schedule of ALL clinical areas distributed (3) days

before the end of the month
Clinical Br
CORE FUNCTIONS
MFO 1: Quality nursing care services
SUPPORT FUNCTIONS
Personnel Satisfaction
Personnel Action Request
Detail Publication
Actual Accomplishments
Ql1
Rating
Qn2
T3
A4
Remarks
MFO 3: Education and Training Services

Competency Report
70% of all Nursing Personnel will undergo Skills Competency

Checklist biannually
Education and Training Br
RN-Residency Program
70% of RN Residents will pass the program requirements prior

to completion at the end of the semester
70% of the RLE exposures of nursing students are

implemented as programmed per semester
70% of P2LTs will pass the Course requirements prior to

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

program completion after one year period
70% of Nursing Personnel should attend at least (3) approved

nursing service training programs biannually
Case Study Report
70% of Clinical Areas satisfactorily presented case studies

biannually
Nursing Service Education and Training

Program
70% of the training plans and programs are conducted and

completed annually
Affiliation
Mentoring Program
AFP Nurse Corps Specialty Training Course
Staff Development Program
MFO 4: Quality Assurance and Research Support Service

90% of the Nursing Clinical areas passed the Nursing Audit at
the end of the semester
NR&QA
At least 2 policies reviewed, revised, and formulated with 0

errors in format at the end of the semester
NR&QA
70% of Nursing Personnel satisfactorily passed the Infection

Control Domain Audit at the end of the semester
HICC
70% of the Clinical Areas submits the PIDSR form on time

every week with 0 errors in format
HICC
Hospital Event Report
All sentinel events are Collected, Analyzed, and Reported with

0 errors in format at the end of the semester
NR&QA
Evidence-Based research
70% of Nurses satisfactorily participate in research activities at

the end of the semester
NR&QA
Nursing Audit Report

Nursing Policies and Procedures
Infection Control Domain Audit
Integrated Disease Surveillance and
Response
CORE FUNCTION
SUPPORT FUNCTIONS
MFO 1: Quality nursing care 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:
Legend: 1 - Quality (Ql)
Date:
2 - Quantity (Qn)
3 - Timeliness (T)
4 - Average (A)
ROLE-RESULTS MATRIX
__NURSING SERVICE DIVISION - WARD 4 C GENITOURINARY _
_______________July to December 2015_______________
Chief Nurse, VLGH
Admin and Support Services
LTC ARLENE V GUTIERREZ NC (GSC) Assistant Chief

Nurse for Clinical Care
Attendance Report
Notice of Discipline
Performance Evaluation
Supplies and Equipment Management
Clinical Area Supervisor
2LT NOVIE CARLA G PAGADUAN NC
Ms Arlene Sales RN II
Nurse
Head Nurse
Assistant Head
(Nurse II, SG-15)
Ms Jennifer Parajes RN II
Manager (Nurse II, SG-15)
Case
Mr Claresto Rhuir Bas-awan RN I

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

I, SG-8)
Monthly Report
Leave Request
Performance Evaluation
(Nursing Attendant
Mentoring and Training Program

Training Recommendation
Staff Orientation (Newly Hired)
(FORM C)
Quality Assurance and Research

Environment of Care Checklist
Incident Reports
Environment of Care Checklist

Incident Reports
Clinical Care
Staff Distribution
Patient Care Supervision
Ward Activities Monitoring
In-patient Census Report
VIP report
In-patient Census Report
Staff Distribution
MERIT / DEMERIT POINTS

CRITERIA
POINTS
Attendance / Punctuality
0.75
MERIT
0.5
DEMERIT
0.25
0 - 1 authorized and informed (3 hours before

duty) absence with no tardiness and no notices
loafing for the whole rating period
0.75
0.5
> 3 authorized or unauthorized per 4 - 6 unauthorized or

month for 3 consecutive months or 3 uninformed absence (3
months per rating period;
hours before duty)
0.25
3 unauthorized or uninformed absence (3 hours
before duty)
6 uninformed (3 hours before duty)

or unauthorized absence for the
whole rating period
Disciplinary Offenses
Non - compliance to
Submission
Performance of Designated
Function
Performing duties of a higher position
19 & above tardiness for the whole

rating period
12 - 18 tardiness for the

whole rating period
9 tardiness for the whole rating period
11 & above notices of loafing
6 - 10 notices of loafing
5 notices of loafing
1 Grave and / or 2 less Grave

Offenses and / or 9 Light Offenses
with a Reprimand or higher
Disciplinary Action
1 Less Grave Offense and 4 Light Offenses with Oral Warning

/ or 6 Light Offense with
Written Warning
(Admonition) Disciplinary
action
Submits Leave Application requests, DTR,

Nursing Unit Reports, Letter of Explanation,
Incident Reports, other documents as
instructed before given deadline
7 & above notices for Late or Non- 4 - 6 notices for Late or

compliance to Submission for the Non-compliance to
whole rating period
Submission for the whole
rating period
Tasked in Nursing Service or Command

Directed Program or Activities
Performing duties of lower position
Tasked as member of Technical Working

Group or Committees
Performed > 16 hours cumulative Training
Instructor and > 8 hours Lecturer duties
3 notices for Late Submission for the whole rating

period
Individual Work Output Table

____Office of the Nursing Service _____
_____________________________________________
________Nurse II SG-15 (Assistant Head Nurse)_________
___________Clinical Care Branch - Infectious Ward (Medical)_______
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
Quality
Timeliness
Quantity
with complete details

within first hour of the shift
all patients
Quality
Timeliness
Quantity
No errors in Standard Protocols

completed within 24 Hours
all patients
Quality
Timeliness
Quantity
No error
all patients
Quality
Timeliness
Quantity
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
PERFORMANCE STANDARDS
Satisfactory
Unsatisfactory
Poor
<100% of patients, within 81-90

minutes, or with 4-5 errors.
<100% of patients, within >90

minutes, or with 6 or more errors.
100% of patients within 24 hours 100% of patients within 24 hours 100% of patients within 24 hours 100% of patients within 48 hours
with 0 (zero) error.
with 1 error.
or with 2-3 errors.
<100% of patients more than 48

hours or with 4-5 errors

hours or with 6 or more errors
100% of patients within 24 hours 100% of patients within 24 hours 100% of patients within 24 hours 100% of patients within 48 hours
with 1 error.
or with 2-3 errors.


No error
completed within shift
all patients
100% of patients within shift with 100% of patients within shift with
0 (zero) error.
0 (zero) error.
100% of patients within shift with

1 error.
<100% of patients within shift or

with 3 errors
<100% of patients within shift or with

4 or more errors
Quality
Timeliness
Quantity
No error
all patients
0 (zero) error.
0 (zero) error.
100% of patients within shift with 100% of patients within shift, with <100% of patients within shift with <100% of patients, within shift with 6
1 error.
2-3 errors.
4-5 errors
or more errors
Quality
Timeliness
Quantity
No error
completed upon discharge
all patients
Quality
Timeliness
Quantity
No error
within shift
all patients
100% of patient within shift with 0 100% of patient within shift with 0 100% of patient within shift with 1 100% of patients within shift with <100% of patients within shift with <100% of patients within shift with 6
(zero) error.
(zero) error
eror.
2 errors.
3-5 error
or more errors
Quality
Timeliness
Quantity
No error
within shift
all patients
100% of patient within shift with 0 100% of patient within shift with 0 100% of patient within shift with 1 100% of patients within shift with <100% of patients within shift with <100% of patients within shift with 6
(zero) error.
(zero) error.
error.
2 errors.
3-5 errors
or more errors
Quality
Timeliness
Quantity
No error
within shift
all E-cart equipments
1. Endorsement Book
Received all patients with complete details within the first hour of
the shift
100% of patients, within the first

hour of shift, with 0 (zero) missed
hour of shift, with 0 error.
data.
100% of patients, within 61-70

minutes, or with 1 error.

2. Patient Assessment Progress Notes

Completed Nursing Assessment Protocol of all Patient within 24
hours
3. Nursing Care Plan
Completed Nursing Care Plan of all patients within 24 hours
4. Medication Administration Record
Completed Medication Protocol of all patients within shift
100% of patients within shift or

with 2 errors.
5. Nursing Procedures Defficiency Monitoring Record

Completed Nursing Procedures Standard Protocol of all patients
within shift
6. Health Teaching Record
Completed Health Teaching Protocol of all patients upon discharge
100% of patients upond

discharge with 0 (zero) error.
100% of patients upon discharge 100% of patients upon discharge 100% of patients upon discharge <100% of patients upon discharge <100% of patients, upon discharge
with 1 error.
with 2 errors.
with 3-5 errors
with 6 or more errors
7. Nursing Progress Notes

Completed Nursing Progress Notes of all patients within shift
8. ISOBAR Defficiency Record
Completed ISOBAR Standard Protocol of all patients within shift
9. Emergency Cart Equipment Record
Complete accounting of Emergency Cart Equipment within shift
100% of Emergency Cart

Equipment within shift with 0
(zero) error.

(zero) error.

error.

errors.
<100% of Emergency Cart

errors.
<100% of patients within shift with 6

or more errors
10. Case Study/Research Paper

Timeliness
excellent substance, with 0-1 missed

data
On or before deadline
Quantity
Complete requirements
Quality
Completed requirements for case study/ research paper biannually
Complete requirements,
Incomplete requirements,
Complete requirements, Excellent
Complete requirements, sufficient
sufficient substance but 1-24
insufficient substance and/or 49Excellent substance, on or before substance, on or before deadline
substance but 25-48 hours after
hours after deadline and/or 2-3
72 hours after deadline and/or 6deadline with 0-1 missed data.
with 0-1 missed data.
deadline and/or 4-5 missed data.
missed data.
7 missed data.
unacceptable substance and/or
more than 72 hours after deadline
and/or more than 8 missed data
100% upon deadline with 0

(zero) error
<100% nurse manager tasks

100% nurse manager tasks upon 100% nurse manager tasks upon 100% nurse manager tasks upon
and/or 24-48 hours after deadline
deadline with 0 (zero) error
deadline with 1-2 errors
deadline with 3-4 errors
and/or with 5-6 errors
<100% nurse manager tasks

and/ormore than 49 hours beyond
deadline and/or with more than 7
uncomplied tasks
100% delegated tasks upon

deadline with 0 (zero)
uncomplied tasks

deadline with 0 (zero) uncomplied
tasks
11. Nurse Manager Role Deficiency Checklist
Performs administrative duties and responsibilities in the

absence / behalf of the Head Nurse
Quality
All tasks complied
Timeliness
upon deadline
Quantity
all delegated tasks
Quality
All tasks complied
Timeliness
upon deadline
Quantity
all delegated tasks
12. Assistive Nurse Manager Deficiency Record

Performs all administrative tasks as directed and as delegated by
the Head Nurse

deadline with 1-2 uncomplied
tasks

deadline with 3-4 uncomplied
tasks
100% delegated tasks 24-48

hours after deadline and /or with
5-6 uncomplied tasks
100% delegated tasks more than 49

hours beyond deadline and/or with
more than 7 uncomplied tasks
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 p
2015.
_______________________
Employee
Date: ___________________
Reviewed by
Date
Approved by
CPT KRISTINA L SALVADOR NC

Immediate Supervisor
Output
LTC CAROLINE D COMMENDADOR NC

Head of Office
Rating
Qn2
T3
Success Indicator (Target + Measure)
100% of patients, within the first hour of shift, with 0 (zero)

missed data
100% of patients, within 71-80 mins, with 0 missed data / error
Patient Assessment Progress

Notes
100% of patients, within 24 hours with 0 (zero) error
<100% of patients within 24 hours with 5 errors
Nursing Care Plan
100% of patients within 24 hours with 2-3 errors
Medication Administration
Record
100% of patients within 24 hours with 0 (zero) error
100%of patients, within shift with 0 (zero) error
100% of patients, within shift with 4-6 errors
Health Teaching Record
100% of patients, upon discharge with (0) zero error
100% of patients upon discharge with 1 error
Nursing Progress Notes
100% of patients, within shift with 0 (zero) error
100% of patients within shift with 2 errors
ISOBAR Deficiency Record
100% of patients, within shift with 6 errors
Ql1
Core Function
Endorsement Book
Nursing Procedures Deficiency

Monitoring Record
Support Function
Emergency Cart Equipment
Record
Case Study / Research Paper

Nurse Manager Role
Deficiency Checklist
Nurse Manager Assistant
Deficiency Checklist
100% of Emergency Cart Equipment within shift with 0 (zero)

error
100% of Emergency Cart Equipment, within shift with 2 errors
Complete requirements, Excellent substance on or before

deadline with 0 (zero) missed data
Complete requirements, Sufficient substance 25 -48 hours after deadline with

2 missed data
100% nurse manager tasks upon deadline with 0 (zero) error
100% nurse manager tasks upon deadline with 5 errors
100% delegated tasks upon deadline with 0 (zero) uncomplied

tasks
100% delegated tasks upon deadline with 4 uncomplied tasks
2.83
2.83
Average point score
2.83
Overall point score
2.83
Intervening point score
0.25
Overall Equivalent Numerical Rating
3.08
Overall Equivalent Adjectival Rating

Comments and Recommendations for Development Purposes
Satisfactory
Discussed with
Date
Assessed by
Date
Final Rating by
I certify that I discussed my assessment of the performance with the

employee
CPT KRISTINA L SALVADOR NC
Employee
Legend:
1 - Quality (Ql) 2 - Quantity (Qn)
Supervisor
3 - Timeliness (T)
4 - Average (A)
LTC CAROLINE D COMMENDA
Head of Office
(FORM E)
d measures for the period from July to December,
______
______
Date
A4
Remarks
3
2
3
10Rs correctly observed and

Adheres to AFPMC Standard
Protocols of Safe Medication
Administration
2
4
3
Disorganized, Incomplete, Faulty

Relay of Information
3
2.83
ory
Final Rating by
LINE D COMMENDADOR NC
Head of Office
Date

_____________________________________________
________Nurse II SG-15 (Case Manager)_________
___________Clinical Care Branch - Female Surgical Ward________
Major Final Outputs
PERFORMANCE
MEASURES
1. Endorsement Book
Receives all patients
Quality
Timeliness
within the first hour of
Quantity
the shift
Quality
Completed Nursing
Timeliness
Assessment Protocol
of all Patient within 24
Quantity
hours
PERFORMANCE TARGETS

all patients
all patients
SUCCESS INDICATOR
Measures + Targets
Outstanding

hour of shift, with 0 (zero) missed
data.
Very Satisfactory
Satisfactory


Unsatisfactory
Poor


minutes, or with 6 or more
errors.
100% of patients within 24 hours 100% of patients within 24 hours


with 1 error.
or with 2-3 errors.
<100% of patients more than 48 <100% of patients more than 48



with 1 error.
or with 2-3 errors.

0 (zero) error.
0 (zero) error.

1 error.
<100% of patients within shift or <100% of patients within shift or

with 3 errors
0 (zero) error.
0 (zero) error.
100% of patients within shift with 100% of patients within shift, with <100% of patients within shift with
1 error.
2-3 errors.
4-5 errors

Completed Nursing
Care Plan of all
patients within 24
hours
Quality
Timeliness
No error
Quantity
all patients

Completed Medication
Protocol of all patients
within shift
Quality
Timeliness
No error
Quantity
all patients

Quality
Timeliness
Completed Nursing
Procedures Standard
Protocol of all patients
Quantity
within shift

with 2 errors.
No error
all patients
<100% of patients, within shift


Completed Health
Teaching Protocol of
all patients upon
discharge
Completed Nursing
Progress Notes of all
patients within shift
8. ISOBAR Defficiency Record
Completed ISOBAR
Standard Protocol of
all patients within shift
Quality
Timeliness
No error
Quantity
all patients
Quality
Timeliness
Quantity
No error
within shift
all patients
Quality
Timeliness
No error
within shift
Quantity
all patients

Quality
Timeliness
Complete accounting
of Emergency Cart
Equipment within shift
Quantity
No error
within shift
100% of patients upond

discharge with 0 (zero) error.
100% of patients upon discharge 100% of patients upon discharge 100% of patients upon discharge <100% of patients upon discharge
<100% of patients, upon
with 1 error.
with 2 errors.
with 3-5 errors
discharge with 6 or more errors
100% of patient within shift with 0 100% of patient within shift with 0 100% of patient within shift with 1 100% of patients within shift with <100% of patients within shift with
(zero) error.
(zero) error.
error.
2 errors.
3-5 errors
<100% of patients within shift

100% of patient within shift with 0 100% of patient within shift with 0 100% of patient within shift with 1 100% of patients within shift with <100% of patients within shift with
(zero) error.
(zero) error.
error.
2 errors.
3-5 errors


(zero) error.

(zero) error.

error.

errors.

errors.


Completed
requirements for case
study/ research paper
biannually
Quality
excellent substance, with 0-1 error
Timeliness
Quantity
Complete requirements, very

Complete requirements, sufficient
sufficient substance 1-24 hours
insufficient substance 49-72
Excellent substance, on or before substance, on or before deadline
substance 25-48 hours after
after deadline and/or with 2-3
hours after deadline and/or with
deadline with 0-1 error.
with 0-1 error.
deadline and/or with 4-5 errors.
errors.
6-7 errors.
unacceptable substance more
than 72 hours after deadline
and/ or with more than 8 errors
11 NCP Template/Clinical Pathway template

Formulate/
Revise/review 4
nursing care plan
templates a month
Quality
0 error in format/substance
Timeliness
within a month
Quantity
4 NCP templates
4 NCP templates within a month

with 0 error
4 NCP templates within a month 3 NCP templates 1-24 hours after

with 0 error
a month and/or with 1-2 error
2 NCP templates 25-48 hours

after a month and/or with 3-4
error
1 NCP templates 49-72 hours

after a month and/or with 5-6
error
unacceptable substance more

and/or with more than 8 errors
12. NCP Compliance Checklist

checks NCP
compliance of nurses
to all patients upon
discharge
Quality
0 error
Timeliness
upon discharge
Quantity
all NCP
100% NCP upon discharge with 100% NCP upon discharge with 0 90% NCP upon discharge and/or 80% NCP upon discharge and/or 70% NCP upon discharge and/or
0 error
error
with 1-2 errors
with 3-4 errors
with 5-6 errors
<70% NCP upon discharge

and/or with more than 7 errors
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 per
2015.
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT KARLA MINA N DELA ROSA NC
Output
Approved by
LTC CAROLINE D COMMENDADOR NC
Head of Office
Rating
Qn2
T3

missed data
100% of patients, within the first hour of shift, with 0 error

Notes
<100% of patients, more than 48 hours or with 4-5 errors
Nursing Care Plan
<100% of patients, more than 48 hours or with 8 errors
Record
100%of patients, within shift with 0 (zero) error
100% of patients, within shift with 3 errors
100% of patients, upon discharge with (0) zero error
<100% of patients, within shift, with 4 errors
100% of patients, within shift with 1 error
100% of patients, within shift with 1 error
Ql1
A4
Core Function
Endorsement Book
Nursing Procedures Deficiency

Monitoring Record
Support Function
Record

error
<100% of Emergency Cart equipment within shift, with 4 errors
Complete requirements, Excellent substance and on or before

deadline with 0 - 1 missed data
Complete requirements, very sufficient substance 5 hours before deadline

with 2 missed data
4 NCP templates within a month with 0 error
3 NCP templates 5 hours after a month with 1 error
100% NCP upon discharge with 0 error
<70 % NCP upon discharge with 10 errors
3.08
3.08
3.08
3.08
NCP Template / Clinical

Pathway template
NCP Compliance Checklist
Average point score

Overall point score
3.08
0.50
3.58

Very Satisfactory
Discussed with
Date
Assessed by
Date
Final Rating by
I certify that I discussed my assessment of the performance with the

employee
CPT KARLA MINA N DELA ROSA NC
Employee
Legend:
Supervisor
3 - Timeliness (T)
4 - Average (A)
LTC CAROLINE D COMMENDAD
Head of Office
(FORM E)
es for the period from July to December,
Date
Remarks
Systematically done and Well
organized
Incomplete and unfilled up NCP

Adheres to the Patient Safety
Standards of Medication
Administration and prudently
observes the 10Rs
Needs to be reminded to check the

E-Cart stock records, low on
initiative
Insufficient and incomplete NCPs,

Needs improvement on systematic
time allocation for NCP formulation
Rating by
COMMENDADOR NC
of Office
Date

Nursing Service Division
_____________________________________________
________Nurse I, SG-11_________
___________Clinical Care Branch - Neuro-Surgical Ward (Ward 4A)________
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR Measures + Targets
Outstanding
Very Satisfactory
Satisfactory
Unsatisfactory
Poor





minutes, or with 6 or more
errors.
1. Endorsement Book
Receives all patients with complete

details within the first hour of the shift
Quality
Timeliness
Quantity
all patients
100% of patients, within the first hour of shift,

with 0 (zero) missed data.
Completed Nursing Assessment

Protocol of all Patient within 24 hours
Quality
Timeliness
Quantity
all patients
Quality
No error
Timeliness
Quantity
all patients
100% of patients within 24 hours with 0 (zero) 100% of patients within 24 hours
error.

with 1 error.
or with 2-3 errors.

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

and/or with 1 error.
and/ or with 2-3 errors.

hours and/or with 4-5 errors

hours and/or with 6 or more
errors

with 3 errors


Completed Nursing Care Plan of all
patients within 24 hours
Completed Medication Protocol of all

patients within shift
Quality
No error
Timeliness
Quantity
all patients
100% of patients within shift with 0 (zero)

error.

0 (zero) error.

1 error.

with 2 errors.
100% of patients within shift with 0 (zero)

error.

0 (zero) error.
1 error.
2-3 errors.
4-5 errors
100% of patients upond discharge with 0

(zero) error.
100% of patients upon discharge 100% of patients upon discharge 100% of patients upon discharge <100% of patients upon discharge
<100% of patients, upon
with 1 error.
with 2 errors.
with 3-5 errors
discharge with 6 or more errors
Completed Nursing Procedures

Standard Protocol of all patients
within shift
Quality
No error
Timeliness
Quantity
all patients

Completed Health Teaching Protocol

of all patients upon discharge
Quality
No error
Timeliness
Quantity
all patients
Completed Nursing Progress Notes

of all patients within shift
Quality
No error
Timeliness
within shift
Quantity
all patients
Quality
No error
Timeliness
within shift
Quantity
all patients
Quality
No error
Timeliness
within shift
Quantity
100% of patient within shift with 0 (zero) error.
100% of patient within shift with 0 100% of patient within shift with 1 100% of patients within shift with <100% of patients within shift with
(zero) error.
error.
2 errors.
3-5 errors

100% of patient within shift with 0 100% of patient within shift with 1 100% of patients within shift with <100% of patients within shift with
(zero) error.
error.
2 errors.
3-5 errors

8. ISOBAR Deficiency Record
Completed ISOBAR Standard

Protocol of all patients within shift
Complete accounting of Emergency

Cart Equipment within shift
100% of Emergency Cart Equipment within

shift with 0 (zero) error.

(zero) error.

Equipment within shift and/or with Equipment within shift and/or with Equipment within shift and/or with
1 error.
2 errors.
3 errors.

and/or with 6 or more errors
Completed requirements for case

study/ research paper biannually
Quality
Timeliness
Quantity
Complete requirements, very Complete requirements, sufficient
Complete requirements, Excellent substance,
sufficient substance and/or 1-24
substance and/or 25-48 hours
insufficient substance and/or 49substance, on or before deadline
more than 72 hours after
on or before deadline with 0-1 error.
72 hours after deadline and/or
with 0-1 error.
deadline and/or with more than
2-3 errors.
errors.
with 6-7 errors.
8 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 mea
July to December, 2015.
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT FELIX RICHARD I MENDOZA NC
Output
Approved by
MAJ NELSON A MANONDO NC
Head of Office
Rating
Qn2
T3

missed data.
100% of patients, within 65 minutes, or with no error.
100% of patients within 24 hours with 0 (zero) error.
<100% of patients, within 48 hours or with 4 errors
Record
100% of patients within shift with 0 (zero) error.
100% of patients within shift with 1 error.
Nurisng Procedures Deficiency

Monitoring Record
100% of patients upond discharge with 0 (zero) error.
100% of patients, upon discharge with 0 (zero) errors
100% of patients within shift with 2 errors.
Ql1
A4
Core Function
Endorsement Book
Notes
Support Function
Nursing Care Plan
Record
100% of patients within 24 hours with 0 (zero) error.
100% of patients within 24 hours with 1 error.

error.
100% of Emergency Cart Equipment within shift with 1 error.
Complete requirements, Excellent substance, on or before

Incomplete requirements, unacceptable substance submitted more

than 72 hours after deadline with 8 errors
Average point score

Overall point score
3.50
3.50 3.50 3.50

3.50
-0.75
2.55
Unsatisfactory
I do not conforme with the rating given to me. I have attached a letter of appeal on this matter
substantial evidences to prove the rating otherwise.
Ms Rei Jean C Dela Pena R
Discussed with
Date
Assessed by
Date
Final Rating by
I certify that I discussed my assessment of the

performance with the employee
Legend:
MS. REI JEAN C DELA PENA RN I
CPT FELIX RICHARD I MENDOZA NC
MAJ NELSON A MANONDO NC
Employee
Supervisor
Head of Office
3 - Timeliness (T)
4 - Average (A)
e indicated measures for the period
__
__
Date
Remarks
Performs Nursing Procedures

prudently and competently
Educates eloquently
Needs Improvement
s matter with
Dela Pena RN
ting by
MANONDO NC
Office
Date

_____________________________________________
________Registered Midwiife II SG-11________
___________Clinical Care Branch - Obstetrics and Gynecology Ward________
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
Satisfactory
Unsatisfactory
1. Vital signs/ I&O Monitoring Sheet

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

report accurate patient
data
Quality
accurate
Timeliness
Quantity
within shift
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.
3. Labor Monitoring Sheet

report accurate progress
of patient labor
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.
4. Midwife Procedures Deficiency Record

Completed midwife
procedures
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
5. EINC Procedure Checklist Deficiency Record
Completed EINC
Procedure Checklist
Quality
No error
Timeliness
Quantity
all patients
6. NAP 5S Deficiency Record

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

within shift with 3 error.
7. Clinical Area Equipment/Supply Record

Complete accounting of
clinical area
supply/Equipment within
shift
Quality
No error
Timeliness
within shift
Quantity
all equipment and supply
8. Midwife Administrative Deficiency Record

Quality
Completed midwife
administrative work
100% of supply/Equipment within 100% of supply/Equipment within 100% of supply/Equipment within 100% of supply/Equipment within <100% of supply/Equipment within
shift with 1 error.
shift with 2 errors.
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors

Completed Health
Teaching Protocol of all
patients upon discharge
Quality
No error
Timeliness
Quantity
all patients
Quality
Timeliness
10. Research / HRDP - COPAR
Completed requirements
for case study/ research
paper biannually

sufficient substance and/or 1-24 substance and/or 25-48 hours insufficient substance and/or 49Excellent substance, on or before substance, on or before deadline
with 0-1 error.
2-3 errors.
errors.
with 6-7 errors.
paper biannually
Quantity

with 0-1 error.
2-3 errors.
errors.
with 6-7 errors.
Poor
<100% of patients, within the

shift or with 6 or more errors.





<100% of supply/Equipment
within shift with 6 or more
errors.


8 errors

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 in
for the period July to December, 2015.
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT ANNABELLE G DELA TORRES NC
Output
Approved by
MAJ SERAFFIN L SORIANO NC
Head of Office
Rating
Qn2
T3
Vital Signs / I&O Monitoring

Sheet
100% of patients, within the shift, with zero (0) error
NAP Critical Patient Reporting

Deficiency Record
Labor Monitoring Sheet
Midwife Procedures Deficiency

Record
EINC Procedure Checklist

Deficiency Record
NAP 5S Deficiency Record
100% of all assigned areas within shift with 0 (zero) error.
Ql1
A4
Core Function
Support Function
Clinical Area Equipment /
Supply Record
Midwife Administrative
Deficiency Record
Research / HRDP - COPAR
100% of equipment/ supply within shift with 0 (zero) error.

Complete requirements, Excellent substance, on or before deadline

with 0-1 error.
Average point score

Overall point score
5.00
Discussed with
Date
Assessed by
Date
5.00 5.00 5.00

5.00
- 0.75
4.25
Outstanding
Final Rating by

Legend:
MS. MARICEL F MORALES RM II
CPT ANNABELLE G DELA TORRES NC
MAJ SERAFFIN L SORIANO NC
Employee
Supervisor
Head of Office
3 - Timeliness (T)
4 - Average (A)
ance with the indicated measures
__
__
Date
Remarks
Well appreciated by co-staff
Well organized
Comprehensive
Systematically performed
Well appreciated by co-staff
Area well maintained

Comprehensive and clearly
understood by patients
Well maintained
Records, Cases, and Birth

Certificate Filing well
maintained and organized
Relevant conducted research
ting by
L SORIANO NC
Office
Date

_____________________________________________
___________Clinical Care Branch - Neonatal Intensive Care Unit (NICU)_____
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
Satisfactory
Unsatisfactory

Quality
Timeliness
accurate
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.

data
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.
3. Neonatal Assessment Deficiency Record

report accurate pediatric
assessment
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.

Completed midwife
procedures
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
Completed EINC
Procedure Checklist
Quality
No error
Timeliness
Quantity
all patients

Accomplished 5s
Quality
No error
Timeliness
Quantity
all assigned areas
shift with 1 error.
shift with 2 error.


clinical area
shift
Quality
No error
Timeliness
within shift
Quantity

Quality
Completed midwife
administrative work
shift with 1 error.
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors

Completed Health
Quality
No error
Timeliness
Quantity
all patients
Quality
Timeliness
paper biannually

with 0-1 error.
2-3 errors.
errors.
with 6-7 errors.
paper biannually
Quantity

with 0-1 error.
2-3 errors.
errors.
with 6-7 errors.
Poor






errors.


8 errors

8 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 accordance with the indicated
period July to December, 2015.
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT CERULLO P MANLAPAT NC
Output
Approved by
MAJ THOMAS O DE CASTRO NC
Head of Office
Rating
Qn2
T3
Vital signs/ I&O Monitoring

Sheet
100% of patients, within the shift, with 3 errors

Deficiency Record
100% of patients, within the shift, or with 1 error.
Neonatal Assessment
Deficiency Record
<100% of patients, within the shift or with 4 errors.

Record

Deficiency Record
Ql1
A4
Core Function
Support Function
100% of all assigned areas within shift with 2 errors.
Clinical Area
Equipment/Supply Record
100% of supply/Equipment within shift with 0 (zero) error.
<100% of supply/Equipment within shift with 10 errors.


with 0-1 error.
Deficiency Record
Average point score

Overall point score
3.20
Discussed with
Date
Assessed by
Date
3.20 3.20 3.20

3.20
-0.25
2.95
Satisfactory
Final Rating by

Legend:
MS. DORINA T SANCHEZ RM II RM II
CPT CERULLO P MANLAPAT NC
MAJ THOMAS O DE CASTRO NC
Employee
Supervisor
Head of Office
3 - Timeliness (T)
4 - Average (A)
with the indicated measures for the
__
__
Date
Remarks
Performs integrated maternal

and child care competently
Was not able to accomplish
most of the EINC Checklist
form
Health Education rendered to

patients on Breast Feeding,
Cord Care, Newborn Bathing
and Immunization follow ups
were conducted
comprehensively
Failed to report unserviceable

ward equipments, incomplete
recording, stock cards were
not updated
ting by
DE CASTRO NC
Office
Date

_____________________________________________
___________Clinical Care Branch - Pediatric Ward (W6C)_____
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
Satisfactory
Unsatisfactory

Quality
Timeliness
accurate
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.

data
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.
3. Pediatric Assessment Deficiency Record

assessment
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.

Completed midwife
procedures
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
5. Pediatric Growth and Development Program Reports
Relevant conduct of all

Integrated Pediatric
Growth and
Development Programs
Quality
Relevant
Timeliness
Quantity
all program reports
100% of conducted relevant

100% of conducted relevant
Integrated Pediatric Growth and Integrated Pediatric Growth and
Development Programs reported Development Programs reported
on or before deadline
on or before deadline
100% of conducted relevant,

sufficient substance Pediatric
Growth and Development
Programs reported and/or 1-24
hours after deadline
100% of conducted relevant,

sufficient substance Pediatric
<100% of conducted irrelevant,

insufficient substance Pediatric

Accomplished 5s
Quality
No error
Timeliness
Quantity
all assigned areas
shift with 1 error.
shift with 2 error.


clinical area
shift
Quality
No error
Timeliness
within shift
Quantity
shift with 1 error.
Completed midwife
administrative work
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors

Completed Health
Quality
No error
Timeliness
Quantity
all patients
Quality
Timeliness
paper biannually

with 0-1 error.
2-3 errors.
errors.
with 6-7 errors.
paper biannually
Quantity

with 0-1 error.
2-3 errors.
errors.
with 6-7 errors.
Poor




<100% of conducted irrelevant,

insufficient substancePediatric
Programs reported and/or more

errors.


8 errors

8 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 measure
to December, 2015.
_______________________
Employee
Date: ___________________
Reviewed by
Date
Approved by
CPT VICTORIA B DE ROCAS NC

Output
LTC DENNIS R FERRER NC

Head of Office
Rating
Qn2
T3
Vital Signs / I&O Monitoring

Sheet
100% of patients, within the shift or with 2-3 errors.

Deficiency Record
<100% of patients, within the shift or with 4-5 errors.
Pediatric Assessment
Deficiency Record
100% of patients, within the shift or with 2-3 errors.

Record
Pediatric Growth and

Development Program Reports
100% of conducted relevant Integrated Pediatric Growth and

Development Programs reported on or before deadline
100% of conducted relevant Integrated Pediatric Growth and

Development Programs reported on or before deadline
Ql1
A4
Core Function
Support Function
<100% of all assigned areas within shift with 8 errors.
Clinical Area Equipment /

Supply Record
<100% of supply/Equipment within shift with 6 errors.
<100% of patients, after the shift with 6 errors


with 0-1 error.
Deficiency Record
Average point score

Overall point score
2.80
Discussed with
Date
Assessed by
Date
2.80 2.80 2.80

2.80
0.00
2.80
Satisfactory
Final Rating by

Legend:
MS. CRESENCIA F MENDOZA RM II
CPT VICTORIA B DE ROCAS NC
LTC DENNIS R FERRER NC
Employee
Supervisor
Head of Office
3 - Timeliness (T)
4 - Average (A)
icated measures for the period July
__
__
Date
Remarks
Proactive involvement on Child

Life Program and Kythe
Foundation activities as well
as on the conduct of School
Readiness Program
Housekeeping complied but

needs to clear clinical area
before endorsement
Clinical Area disorganized and

supplies not properly labeled
and placed on proper
container
Needs improvement on
reporting and recording of
childhood illnesses and
pediatric ward prevalent cases
Very relevant
ting by
FERRER NC
Office
Date

_____________________________________________
________Registered Midwiife I SG- 9________
___________Clinical Care Branch - Obstetrics and Gynecology Ward (OBGYN)_______
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
Satisfactory

Quality
accurate
Timeliness
within shift
Quantity
all patients
100% of patients, within the shift, 100% of patients, within the shift, 100% of patients, within the shift, 100% of patients, within the shift
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
2. NAP Deficiency in Reporting Critical Patient Data Record

Quality
report accurate patient data
Timeliness
Quantity
Completed midwife
procedures
accurate
within shift
all patients
Quality
No error
Timeliness
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
0 (zero) error.
0 (zero) error.
100% of patients within shift with 100% of patients within shift, with
1 error.
2-3 errors.
4. Labor Monitoring Sheet

report accurate progress of
patient labor
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
Completed EINC Procedure

Checklist
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.

Accomplished 5s standard
at all assigned areas within
the shift
Quality
No error
Timeliness
Quantity
all assigned areas
shift with 1 error.
shift with 2 error.

nursing supply/Equipment
within shift
Quality
No error
Timeliness
within shift
Quantity
100% of supply/Equipment within 100% of supply/Equipment within 100% of supply/Equipment within 100% of supply/Equipment within
shift with 1 error.

Completed Health Teaching
Protocol of all patients upon
discharge
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
CE STANDARDS
Unsatisfactory
Poor
<100% of patients, within the shift

or with 4-5 errors.


or with 4-5 errors.

<100% of patients within shift with

4-5 errors


or with 4-5 errors.


4-5 errors



<100% of supply/Equipment within

errors.

4-5 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 accordance with the indicate
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT GRACE MARIE N SANTOS NC
Output
Approved by
LTC JAMES PAUL C DEL ROSARIO NC
Head of Office
Rating
Qn2
T3

Sheet
100% of patients, within the shift or with 2 errors.
NAP Deficiency in Reporting

Critical Patient Data Record
100% of patients within shift, with 3 errors.

Deficiency Record
Ql1
A4
Core Function

Record
Labor Monitoring Sheet
Support Function
100% of all assigned areas within shift with 2 error.
Clinical Area
100% of supply/Equipment within shift with 2 errors.
Average point score

Overall point score
3.25
Discussed with
Date
Assessed by
Date
3.25 3.25 3.25

3.25
0.50
3.75
Very Satisfactory
Final Rating by

Legend:
MS. LORENA P CRUZ RM I
CPT GRACE MARIE N SANTOS NC
Employee
Supervisor
3 - Timeliness (T)
4 - Average (A)
LTC JAMES PAUL C DEL ROSARIO

Head of Office
with the indicated measures for the
__
__
Date
Remarks
ting by
DEL ROSARIO NC
Office
Date

_____________________________________________
________Registered Midwiife I SG-9________
___________Clinical Care Branch - Neonatal Intensive Care Unit (NICU)____
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
Satisfactory
Unsatisfactory

Quality
Timeliness
accurate
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.

data
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.
3. Neonatal Assessment Deficiency Record

assessment
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.

Completed midwife
procedures
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
Completed EINC
Procedure Checklist
Quality
No error
Timeliness
Quantity
all patients

Accomplished 5s
Quality
No error
Timeliness
Quantity
all assigned areas
shift with 1 error.
shift with 2 error.


clinical area
shift
Quality
No error
Timeliness
within shift
Quantity
shift with 1 error.

Completed Health
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
Poor






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 accordance with the ind
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT CHRISTIAN RAEGAN L IGNACIO NC
Output
Approved by
LTC MARIA AURORA O TORRES NC
Head of Office
Rating
Qn2
T3

Sheet

Deficiency Record
Neonatal Assessment
Deficiency Record

Record

Deficiency Record
Ql1
A4
Core Function
Support Function
Clinical Area
100% of supply/Equipment within shift with 2 errors.
Average point score

Overall point score
3.00
Discussed with
Date
Assessed by
Date
3.00 3.00 3.00

3.00
0.75
3.75
Very Satisfactory
Final Rating by
I certify that I discussed my assessment of the performance

with the employee
Legend:
MS. CRISTINA C VALENCIANO RM I
CPT CHRISTIAN RAEGAN L IGNACIO NC
Employee
Supervisor
3 - Timeliness (T)
4 - Average (A)
LTC MARIA AURORA O TORR

Head of Office
e with the indicated measures for the
___
___
Date
Remarks
Rating by
ORA O TORRES NC
of Office
Date

_____________________________________________
________Registered Midwiife I SG-9_______
___________Clinical Care Branch - Pediatric Ward (W6C)_____
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
Satisfactory
Unsatisfactory

Quality
Timeliness
accurate
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.

data
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.
3. Pediatric Assessment Deficiency Record

assessment
Quality
accurate
Timeliness
within shift
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
or with 4-5 errors.

Completed midwife
procedures
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors

Accomplished 5s
Quality
No error
Timeliness
Quantity
all assigned areas
shift with 1 error.
shift with 2 error.


clinical area
shift
Quality
No error
Timeliness
within shift
Quantity
shift with 1 error.
Completed midwife
administrative work
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
4-5 errors

Completed Health
Quality
No error
Timeliness
Quantity
all patients
Poor





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 indic
the period July to December, 2015.
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT CARLITO D RENANTE NC
Output
Approved by
MAJ TROY KELLY F DUMAMPILIS NC
Head of Office
Rating
Qn2
T3

Sheet

Deficiency Record
Pediatric Assessment
Deficiency Record

Record
<100% of patients, within shift with 10 errors
Ql1
A4
Core Function
Support Function
Clinical Area
100% of supply/equipment within shift with 0 (zero) error.
100% of supply/equipment within shift with 1 error.
Deficiency Record
Average point score

Overall point score
3.63
Discussed with
Date
Assessed by
Date
3.63 3.63 3.63

3.63
0.25
3.88
Very Staisfactory
Final Rating by

Legend:
MS. MARIA CONSOLACION D RODRIGUEZ RM I
CPT CARLITO D RENANTE NC
Employee
Supervisor
3 - Timeliness (T)
4 - Average (A)
MAJ TROY KELLY F DUMAMPILIS

Head of Office
e with the indicated measures for
__
__
Date
Remarks
ting by
DUMAMPILIS NC
Office
Date

_____________________________________________
________Nursing Attendant II SG-6________
___________Clinical Care Branch - Dermatology Ward (W6D)________
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
Satisfactory

Quality
Timeliness
Quantity

data
Quality
Timeliness
Quantity
3. Delegated Nursing Procedure Deficiency Record
Completed delegated
nursing procedure
accurate
within shift
all patients
accurate
within shift
all patients
Quality
No error
Timeliness
Quantity
all patients
Quality
No error
Timeliness
Quantity
all assigned areas
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.

Accomplished 5s
standard at all
assigned areas within
the shift
shift with 1 error.
shift with 2 error.
5. Nursing Equipment/Supply Record

Complete accounting
of nursing
supply/equipment
within shift
Quality
No error
Timeliness
within shift
Quantity
shift with 1 error.
6. Delegated Nursing Administrative Deficiency Record

Completed delegated
nursing administrative
work
Quality
No error
Timeliness
Quantity
all delegated tasks
100% of delegated tasks within



shift with 1 error.

shift, with 2-3 errors.


100% ofdelegated tasks within

shift with 1 error.

shift, with 2-3 errors.
7. NAPIC Management Deficiency Record

Completed NAPIC
delegated
administrative work
Quality
No error
Timeliness
Quantity
all delegated tasks
E STANDARDS
Unsatisfactory
Poor

or with 4-5 errors.


or with 4-5 errors.


4-5 errors




errors.
<100% of delegated tasks within

<100% of delegated tasks,
shift with 4-5 errors
within shift with 6 or more errors
<100% of delegated tasks within

<100% of delegated tasks ,
shift with 4-5 errors
within shift with 6 or more errors
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 accordance with the indicated mea
July to December, 2015.
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT RICHARD F DELA PENA NC
Output
Approved by
LTC RICARDO F SANTOS NC
Head of Office
Rating
Qn2
T3

Sheet

Delegated Nursing Procedure

Deficiency Record
100% of delegated tasks within shift with 0 (zero) error.
100% ofdelegated tasks within shift with 0 (zero) error.
Delegated Nursing
Administrative Deficiency
Record
Ql1
A4
Core Function
Support Function
Nursing Equipment/Supply
Record
NAPIC Management
Deficiency Record
Average point score

Overall point score
5.00
5.00 5.00
5.00
5.00
5.00
Outstanding
Discussed with
Date
Assessed by
Date
Final Rating by

Legend:
MS. MARITESS V DELA CRUZ NA II
CPT RICHARD F DELA PENA NC
Employee
Supervisor
Head of Office
3 - Timeliness (T)
4 - Average (A)
e indicated measures for the period
__
__
Date
Remarks
Accurately and competently

done
Well appreciated by co-staf
Well appreciated by co-staf
Administrative reporting well

organized and complete
Clinical Area well maintained

and neat
Well maintained and Stock
Cards are updated
Well organized
ting by
F SANTOS NC
Office
Date

_____________________________________________
________Nursing Attendant I SG-4________
___________Clinical Care Branch - Dermatology and Burn Unit Ward (W6D)________
Major Final Outputs
PERFORMANCE
MEASURES
PERFORMANCE TARGETS
SUCCESS INDICATOR
Measures + Targets
Outstanding
Very Satisfactory
Satisfactory

Quality
Timeliness
Quantity
accurate
within shift
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.

data
Quality
Timeliness
Quantity
3. Delegated Nursing Procedure Deficiency Record
Completed delegated
nursing procedure
accurate
within shift
all patients
Quality
No error
Timeliness
Quantity
all patients
with zero (0) error
with zero (0) error
or with 1 error.
or with 2-3 errors.
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.

Accomplished 5s
standard at all
assigned areas within
the shift
Quality
No error
Timeliness
Quantity
all assigned areas
shift with 1 error.
shift with 2 error.
5. Nursing Equipment/Supply Record

Complete accounting
of nursing
supply/equipment
within shift
Quality
No error
Timeliness
within shift
Quantity
shift with 1 error.
6. Delegated Nursing Administrative Deficiency Record

Completed delegated
nursing administrative
work
Quality
No error
Timeliness
Quantity
all patients
0 (zero) error.
0 (zero) error.
1 error.
2-3 errors.
E STANDARDS
Unsatisfactory
Poor

or with 4-5 errors.


or with 4-5 errors.


4-5 errors




errors.

4-5 errors

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 accordance with the indica
_______________________
Employee
Date: ___________________
Reviewed by
Date
CPT GERARD T DE MESA NC
Output
Approved by
Head of Office
Rating
Qn2
T3

Sheet

Delegated Nursing Procedure

Deficiency Record
Delegated Nursing
Administrative Deficiency
Record
Ql1
A4
Core Function
Support Function
Nursing Equipment/Supply
Record
Average point score

Overall point score
5.00
Discussed with
Date
Assessed by
Date
5.00 5.00 5.00

5.00
-0.50
4.50
Outstanding
Final Rating by

Legend:
MS. MARICRIS A DELA RUIZ NA I
CPT GERARD T DE MESA NC
Employee
Supervisor
Head of Office
3 - Timeliness (T)
4 - Average (A)
e with the indicated measures for the
__
__
Date
Remarks
Well Organized
Systematic
Well Appreciated by co-staff
Well Appreciated by co-staff
Well Maintained
Well Maintained
ting by
F SANTOS NC
Office
Date
(FORM F)
Daily Individual Work Output Journal
________________(Office)_________________
DATE:
__________________(Name)__________________
__________________(Position/SG)__________________
__________________(Division)__________________
Div
Output ID
No.
Subject
Prepared by:
Employee's Name and Signature
Output
Assigned
Time
Accomplished
Revision No.
Quality
Quantity
Noted by:
Supervisor's Name and Signature
Remarks
Weekly Consolidated Individual Work Output Table

________________(Office)_________________
PERIOD COVERED:
__________________(Name)__________________
_________________(Position/SG)_________________
__________________(Division)__________________
Div
Output ID
No.
Date
Output
Maximum Time
Completed
No. of Revisions
Quality
Quantity
Supervisor's Comments:
Prepared by:
Employee's Name and Signature
Date: ________________
Reviewed / Noted by:
Supervisor's Name and Signature
Date: _________________
Remarks
Performance Monitoring and Coaching Journal
Name of Division _________________________________

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

Office A
Performance Assessment: Very Satisfactory
Division A
Rating
Numerical
Division A Rating
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
No. of Employees = 5 Average
ratings of staff
Division B
Rating
Numerical
Division B Rating
Employee 1
Employee 2
Employee 3
Employee 4
ratings of staff
Division C
Rating
Numerical
Division C Rating
Employee 1
Employee 2
Employee 3
Employee 4
ratings of staff
Summary:
Division A
Division B
Division C
Average
12/3=
4
3
5
4
Very Satisfactory
Satisfactory
Outstanding
Very Satisfactory
(Form I)
erformance Rating
nt: Very Satisfactory

Rating
Adjectival
Rating
Adjectival
Rating
Adjectival
Performance Rewarding and Development
Professional Development Plan

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

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Office Performance Output Table

100% acceptability upon 3 presentations

List of Foreign and Local Training Programs

1 approved list of foreign and local training programs

Local and Foreign Travels Assisted

completed before the start of every calendar year

1 approved training calendar per year

completed before the start of every calendar year

MFO 2: Human Resource Management Interventions

Military Personnel Actions

100% of required personnel actions undertaken

MFO 3: HR Policy / Program Design Implementation, Monitoring, and Evaluation

Updated Citizen's Charter

100% acceptability upon 3 presentations

100% acceptability upon 3 presentations

Updated GIP / OJT Guidelines

updated GIP / OJT guidelines approved

100% acceptability upon 3 presentations

Office Supplies Management

90% responsiveness to clients' needs

90% acceptability of supplies delivered

Office Transport Operations

1 Document Tracking System designed

Office Financial Services

100% budgeting and financial requirements acted upon

1 HR / CD Plan completed before the start of the

1 APB developed within prescribed timeframe with 100%

1 approved training calendar per year to be completed

1 approved list of foreign and local training programs to

17 training designs approved upon 2 presentations for

33 trainings conducted and accomplished within the

100% of local and foreign travels assisted within 1 day

undertaken 100% of required personnel actions within

100% of documents acted upon within 3 days for priority

90% of personnel data inputted and 100% updated

1 handbook drafted within the prescribed timeline with

updated IPPMS guidelines approved within set deadline

3 Integrity Development Policies developed within the

5 GAD Policies developed within the prescribed timeline

updated Citizen's Charter approved within set deadline

1 HR Plan completed within the prescribed timeline with

updated GIP / OJT guidelines approved within set

1 Document Tracking System designed within set

100% requested supplies delivered within 2 days upon

100% budgeting and financial requirements acted upon

100% of requested transport needs supplied within

LTC ANTONIO G PUNZALAN MC (GSC)

COLONEL EDWIN LEO T TORRELAVEGA MC (GSC)

SUCCESS INDICATORS (TARGETS + MEASURES)

5426 patients treated per semester

85% Level of Satisfaction of all patients towards nurses per month

70% Average Score from the Level of Satisfaction of All Nursing

70% of all personnel action request accomplished within (3)

70% of All Personnel appraisal is accomplished and submitted with 0

70% of all the Nursing Personnel disciplinary actions monitored

Sterile Supplies Processing

100% of All Issued Supplies for 24 hours are Sterile

Attendance and Punctuality

100% of all Nursing Personnel's attendance and punctuality will

90% of approved schedule of ALL clinical areas distributed (3) days

MFO 3: Education and Training Services

70% of all Nursing Personnel will undergo Skills Competency

Education and Training Br

70% of RN Residents will pass the program requirements prior