Level 3 Self Assessment Geriatric Nursing 1

Republic of the Philippines
DEPARTMENT OF HEALTH
NURSE CERTIFICATION PROGRAM
Self-Assessment Tool for Level 3 Certification in Geriatric Nursing
Name of Candidate: __________________________________________________________________

Hospital of current employment: ________________________________________________________
Introduction: A nurse Candidate who seeks to be certified as a specialist in Geriatric Nursing, Level
3, will have to accomplish this self-assessment form and prepare the needed evidence to show proof of
competence. Upon accomplishment of the form, the candidate will discuss the data and the evidence with
his/her immediate supervisor for validation. It may be necessary to revise responses based on this
discussion. The Candidate then submits to the Committee on Assessment and Certification the validated
self-assessment tool and supporting evidence for review and assessment by the independent Assessors,
who will determine competency or recommend development opportunities.
This Self-Assessment Tool is both formative and summative. As such it provides information as to the
areas and levels of competency of the Candidate with respect to the standard performance criteria. It also
informs on competency gaps and therefore provides the Candidate with leads on which learning and
development interventions he/she should undertake.
Instructions: The first column in the table lists behavioural indicators that determine
successful/outstanding performance in the workplace. In order to provide a calibrated picture of the
Candidate’s proficiency at demonstrating these behaviors, the tool uses a three-point rating scale that
indicates standards of demonstrating a behavior in a given situation at the workplace.
After accomplishing the Self-Assessment Tool, take it for discussion and validation to your Immediate
Supervisor, with the accompanying evidence to prove statements of competence. In your respective
specialty area. Submit the validated tool and evidence to the Committee on Assessment and Certification.
Indicate with a tick mark in the corresponding box areas in the hospital where you are currently
assigned (most of the time) to provide nursing services:
Ward OPD DR OR ER
NICU PICU MICU SICU RR
CCU CVLab Nursery PDU CAPD Clinic
HDU Others
Validated by:
________________________________________________ ______________
Signature over Printed Name of Immediate Supervisor Date Signed
DOH NCP-CAC Self-Assessment Tool (Form 1) P a g e |1

Revision 0, April 2013
Place a tick mark in the corresponding standards column if you fulfill the corresponding evidences to the behaviors listed in the competency criteria.
Consistency in demonstrating the specified behaviour while meeting the standard required for performance is gauged using the standards:
Satisfactory, Very Satisfactory, Outstanding.
Competency Level 3: Perform comprehensive Geriatric Assessment in collaboration with health care team members NCGERL3A01
Task Description: Evaluates the candidate’s ability to obtain relevant health information and history from patient, family, caregiver, and
significant other utilizing standardized geriatric assessment tool (CGA) taking into account age, gender and cultural background
Criteria Satisfactory Very Satisfactory Outstanding
Performs comprehensive physical examination Able to accomplish 1 out of Able to accomplish 2-3 out Able to accomplish 4 out of
As evidenced by: 4 criteria of 4 criteria 4 criteria
● Completed performance checklist of CGA to
eligible patients.
● Coordinated completion of CGA with other
members of the healthcare team.
● Completed data which includes the 5
domains:
3.1 Physical and Health Illness Condition 3.2
Functional ability
3.3 Psychological ability
3.4 Cognitive ability
3.5 Social Support System
● Accomplished geriatric screening tools
● Documented findings: subjective and
objective information
Assesses health history from the patient and family,

caregiver, and significant others as necessary
As evidenced by:
● Completed checklist of actual performance of
physical examination (cephalocaudal)
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● Documented physical examination

● Documented findings gathered after physical
examination
Recognizes developmental, age related changes and

gender specific variations
As evidenced by:
● Documentation in Nurse’s Notes
● Documented findings gathered after physical
examination.
Assesses for health promotional and disease

prevention needs
As evidenced by:
● Documented findings gathered
Competency Level 3: Provide services designed to promote health, prevent illness, and achieve optimal recovery from or adaptation to health
problems NCGERL3A02
Task Description: Evaluates the candidate’s ability to obtain relevant health information and history from patient, family, caregiver, and
significant other utilizing standardized geriatric assessment tool (CGA) taking into account age, gender and cultural background
Assesses the adequacy of and/or need to establish an Able to accomplish 1-4 out Able to accomplish 6-7 out Able to accomplish 8-10
advance care plan of 10 criteria of 10 criteria out of 10 criteria
As evidenced by:
● Documented information gathered in Nurse’s
Notes
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● Documented recommendations which

include but not limited to:
▪ Level or type of care
▪ Financial status
▪ Need for assistance (e.g.
elderly abuse, nursing home
placement)
Correlates CGA results with assessment result for

health promotion and disease prevention needs of the
patient
As evidenced by:
● Documented summary of CGA results
● Documented utilization of data from CGA as
guide in relationship to the following:
● Activity level
● Mobility
● Cognition
● Decision-making capacity
● Pain
● Skin integrity
● Nutrition
● Sexuality
● Immunization status
● Neglect and abuse
● Substance use and abuse
● Quality of life
● Genetic risks
● Health risk behaviors
● Safety
● Advance planning preferences
Documents summary of needs for health promotion
and disease prevention plans
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As evidenced by:
● Documented findings gathered
Identifies acute and chronic health problems and

genetic risks and health risk behaviour observed
As evidenced by:
● Completed checklist on performance of
screening for acute and chronic health
problems and risk assessment
Refers for acute and chronic health problems and

genetic risks and health risk behavior
As evidenced by:
● Document findings based on clinical
evidences available
● Documented referral of findings gathered
Secures attachment of clinical evidences (laboratory

and diagnostic results) in patient’s chart
As evidenced by:
● Completed clinical results in the chart
● Documented findings based on clinical
evidences available
● Other forms
Determines polypharmacy; drug interactions and

other adverse events; over-the-counter;
complimentary alternatives; and the ability to obtain,
purchase, self-administer, and store medications
safely and correctly
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As evidenced by:
● Completed comprehensive assessment data
about pharmacologic regimen of the patient
in patient’s therapeutic sheet and medication
handbook
● Documented polypharmacy in appropriate
sheets
● Accomplished Beer’s criteria
Evaluates the patient’s and family’s readiness,

coping and management skills in facing the
developmental (life stage) transitions
As evidenced by:
● Accomplished interview documentation with
the patient and family and/or collateral
sources
● Accomplished assessment tool: Caregiver’s
Strain Index
● Documented information gathered
Determines the patient’s need for transition to a

different level or type of care based on individual’s
acuity, stability, resources, and need for assistance
As evidenced by:
● Documented information gathered
● Documented recommendations which
include but not limited to:
▪ Level or type of care
▪ Financial status
▪ Need for assistance (e.g.
elderly abuse, nursing home
placement)
● Completed referral form
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Determines the need for advance care plan
As evidenced by :
● Accomplished actual interview with the
patient and family and/or collateral sources
● Completed standardized assessment
● Documented information gathered from the
interview of patient and collateral sources.
Competency Level 3: Identify age-related changes, presence of co-morbidities, and its impact on presenting health problems NCGERL3A03
Task Description:
Evaluates the candidate’s ability to facilitate appropriate use of laboratory, diagnostic testing and clinical procedures for screening and/or disease
prevention strategies in collaboration with the attending physician with consideration of the cost, risks, and benefit to the patient presence of co-
morbidities, age-related changes and, its impact on presenting health problems, potential for rapid physiologic and mental health deterioration or
life-threatening
Identifies the presence of co-morbidities, age-related Able to accomplish 1-2 out Able to accomplish 3-4 out Able to accomplish 5 out of
changes, physiologic and mental health deterioration of 5 evidences of 5 evidences 5 evidences
or life-threatening instability
As evidenced by:
● Documentation of actual performance of
CGA
● Documentation of accurate and
comprehensive information gathered from
the interview of patient and collateral sources
(subjective data) and physical examination
(objective data)
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● Secure clinical evidences that will support

the identification of co-morbidities and other
health problems presented by the patient
Recognizes geriatric syndromes and constellations of

symptoms that may be manifestations of other
common health problems
As evidenced by:
● Accomplished summary of results and
recommendation from CGA
● Documented accurate information gathered
from the interview of patient and collateral
sources (subjective data) and clinical
evidences (objective data)
● Secure clinical evidences (attached to chart)
that will support the identification of geriatric
syndromes presented by the patient
Facilitates appropriate use of laboratory, diagnostic

testing and clinical procedures for screening and/or
disease prevention strategies in collaboration with
the attending physician
As evidenced by:
● Accomplished requests of
laboratory/diagnostic testing
● Completed clinical evidences (attached to
chart) that will support the identification of
geriatric syndromes presented by the patient
● Accomplished request form of laboratory,
diagnostic testing and clinical procedures
● Documented facilitation of the procedure/s
and result/s in the Nurses Notes.
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Interprets and utilizes data obtained from the use of

invasive and non-invasive monitoring modalities for
appropriate management, consultation and referral
As evidenced by:
● Documented information according to
sources
● Completed attachment of laboratory and
diagnostic testing and/or clinical procedures
result
● Documented facilitation of the procedure and
result in the Nurses Notes.
Prioritizes identified problems and needs based on

patient information, history, physical exam, and
diagnostic data
As evidenced by:
● Accomplished summary of results which
shows identified problems in ranks
(ie.emergent, urgent,)
● Documentation of prioritized problems
identified based on information gathered
from the history, physical exam, and clinical
evidences
● Completed attachments of clinical evidences
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Competency Level 3: Develop short and long term goals for plan of care using SMART method NCGERL3A04
Task Description: Evaluates the ability of the candidate to develop short and long term goals for plan of care using SMART method and their
ability of the candidate to formulate nursing care plan parallel to and in in collaboration with multidisciplinary team
Develops short and long term goals for plan of care Able to accomplish 1-2 out Able to accomplish 3-4 out Able to accomplish 5 out of
using SMART method of 5 criteria of 5 criteria 5 criteria
As evidenced by:
● Documentation of the formulated nursing
care plan
● Copy of integrated and collaborative plan of
care involving multidisciplinary team members ●
Complete nursing care plan for:
a. Health maintenance
b. Disease prevention
c. Therapeutic interventions
Formulates individualized nursing care plan which

include but not limited to health maintenance,
disease prevention and therapeutic interventions to
achieve desired patient outcome in collaboration
with multidisciplinary team
As evidenced by:
care plan
● Documentation of collaborative plan of care
involving multidisciplinary team members
● Complete nursing care plan for:
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Develops individualized nursing care plan in
collaboration with multidisciplinary team
As evidenced by:
care plan
● Documentation of collaborative plan of care
involving multidisciplinary team members
● Accomplished and documented
individualized nursing care plan for:
Develops plan for age-appropriate health screening

and health wellness program
As evidenced by:
● Documentation of the formulated Program
Plan attached to patient’s record
● Documentation of involvement of
multidisciplinary team members in
developing the plan
● Complete Program plan which includes:
1. Data on risk factors present/ identified
2. Interventions done for health promotion/
healthy lifestyle
3. Evaluation
Prepares a discharge plan for short and long term
care
As evidenced by:
● Documentation of comprehensive discharge
plan for short and long term care attached to
patient’s record
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● Documentation of involvement of
multidisciplinary team members in
developing the plan
● Complete Discharge Plan which includes:
1. Data on risk factors present/ identified
2. Interventions done for health promotion/
healthy lifestyle
3. Evaluation
Competency Level 3: Implement plan of care based on evidence-based best practices NCGERL3A05
Task Description:Evaluates ability of the candidate to implement and consequently modify nursing care plan depending on outcomes and
response of patient to treatment and care
Creates plan of care on actual problem identified Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
3 criteria 3 criteria 3 criteria
As evidenced by:
● Accomplished nursing interventions
appropriate to the nursing problem identified
in:
o Nurses notes
o CGA monitoring sheet (Nurses’
sheet)
● Documentation of management of at least 2
of the common geriatric syndrome
algorithms
● Other forms
Implements plan of care for potential

problem/sidentified based on evidence-based best
practices
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As evidenced by:
● Documentation of evidence-based nursing

interventions
● Accomplished nursing interventions
appropriate to the nursing problem identified
in:
o Nurses notes
o CGA monitoring sheet (Nurses’
sheet)
Implements plan of care for health wellness and

promotion based on evidence-based best practices
As evidenced by:
● Demonstration of nursing interventions

requiring prioritization as documented in the
Nurses Notes utilizing FDAR method
● Documentation of evidence-based nursing
interventions in Nurses notes
● Accomplished checklist in discussion of at
least 1 complex acute problem identified and
interventions provided according to
evidence-based best practices
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Competency Level 3: Monitor patient’s response to care and makes appropriate recommendations NCGERL3A06
Task Description: Evaluates the candidate’s ability to monitor and assess outcomes of care, and formulate recommendations
Assesses for patient’s response to care Able to accomplish 1 out Able to accomplish 2 out of Able to accomplish 3 out of
As evidenced by: of 3 criteria 3 criteria
● Documentation of patient’s response to 3
nursing interventions in criteria
1.Progress notes
2.Nurses Notes
● Written reports from doctors, supervisors and
colleagues
● Demonstration on evaluating patient’s
condition
Creates recommendations for appropriate management
As evidenced by:
● Documentation of patient’s response to
nursing interventions in
1.Progress notes
2.Nurses Notes
colleagues
condition
Performs preliminary screening to determine
whether a full multidisciplinary evaluation is needed
As evidenced by:
● Documentation of patient’s response to
nursing interventions
1.1 Progress notes
colleagues
condition
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Competency Level 3: Educate patient, family and caregiver utilizing individualized teaching plan NCGERL3B01
Task Description: Evaluates the candidate’s ability to provide patient-specific and additional information relevant to
promotion of health, prevention and continuing care
Assesses the patient’s learning needs Able to accomplish 1-2 out Able to accomplish 3-4 out Able to accomplish 5-6 out
As evidenced by: of 6 criteria of 6 criteria of 6 criteria
● Documentation of assessment of patient and
family’s level of understanding
● Documentation of patient’s health condition
● Accomplishedassessment of patient and
family’s response inNurses Notes
● Accomplished Health Education log book
Creates an effectivelearning environment

As evidenced by:
● Documentation of provision of health education
in an environment conducive for learning
● Documentation in
1.Nurses Notes
2.Client’s feedback form
Designs an individualized teaching plan of identified

problem/s which include the following: health
condition, medications, activities, diet and
precautions, and schedule of follow-up
As evidenced by:
● Comprehensive individualized teaching plan
focusing on each specific problem
1. Nurses Notes
2. Teaching plan
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Formulates individualized teaching plan
As evidenced by:
● Comprehensive individualized teaching plan
focusing on a specific problem
● Documented in
1. Nurses Notes
2.Teaching plan
Educates patient, family, and caregiver utilizing the

teaching plan
As evidenced by:
● Documentation of health education in
1. Nurses Notes
2. Health Education log book
3. Patient evaluation/feedback form
● Documentation of patient’s response from
the health education in Nurses Notes
● Documentation of family/SO’s response
from the health education.
Evaluates the outcomes of health education
As evidenced by:
1.Nurses Notes
2.Health Education log book
● Patient/Client’s satisfaction survey
● Family/SO’s satisfaction survey
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Competency Level 3: Utilize culturally appropriate communication skills adapted to patient’s and family’s cognitive, developmental, physical,
cognitive and behavioral status NCGERL3C01
Task Description: Evaluates the ability of the candidate to provide the patient and his/her family all information relevant to the patient’s care
and elicit collaboration from them to achieve positive outcomes
Creates a climate of warmth, mutual trust and Able to accomplish 1-4 out Able to accomplish 5-7 out Able to accomplish 8-10
acceptance with consideration of environment and of 10 criteria of 10 criteria out of 10 criteria
client’s status
As evidenced by:
o Nurses Notes
● Performance Evaluation by immediate
supervisor
Recognizes barriers to communication
As evidenced by:
o Nurses Notes
supervisor
● Other forms
Determines common physiological changes

associated with aging that interfere with
communication which may include but not limited to
high-frequency hearing loss, loss of dentition,
reduced vital capacity, and reduced oral motor
function
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As evidenced by:
1. Nurses Notes (inclusion of any of the
following:)
1.1 Age-related sensory changes
1.2 Disease and disability
1.3 Psychological barrier
1.4 Environmental factors
supervisor
Utilizes therapeutic communication skills applicable

to geriatric patients
As evidenced by:
● Documentation in Nurses Notes and
supervisor
Provides interactive communication with the older

persons and family/significant others
As evidenced by:
supervisor
Uses culturally appropriate communication skills

adapted to individual’s cognitive, developmental,
physical, mental and behavioral health status
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As evidenced by:
supervisor
Records pertinent information about the patient

accurately using prescribed forms and recording
system
As evidenced by:
1. Nurses Notes utilizes FDAR
appropriately
2. Patient’s medical record or medical forms
prescribed by the institution
Utilizes the referral system to communicate

identified problems to the members of the health
team and other disciplines following SBAR
As evidenced by:
1. Nurses Notes utilizes FDAR appropriately
2. Patient’s medical record or medical forms
prescribed by the institution
Provides clinical information and/or identified

problems to other members of the health care team
significant in the management of the patient
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As evidenced by:
1.Nurses Notes
2.SBAR format
● Referral form
Communicates comprehensive plan of care to

receiving clinicians and healthcare team during
transition
As evidenced by:
1.Nurses Notes
2.SBAR format
● Referral form
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Competency Level 3: Establish collaborative working relationships within nursing and other members of the health care team in planning and
providing care for the clients NCGENL3D01
Task Description: Evaluates the ability of the candidate to contribute to the services, decisions and actions of the healthcare team in delivering
care to the patient
Refers to members of the multidisciplinary team Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
based on the needs of the patient 3 criteria 3 criteria 3 criteria
As evidenced by:
● Documentation in Nurses’ Note and
Treatment Record Sheet
● Accomplished Nursing Care Plan
● Completed referral Forms
● Other related forms
Documents proper attachments or appropriate forms
for referrals made
As evidenced by:
● Completed Referral Forms
● Accomplished Informed Consent Forms
● Other means
Attends to the needs of the patients promptly based
on the referrals made
As evidenced by:
● Accomplished Nursing Care Plan
● Evaluation in Patient Feedback Form
● Other means
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Competency Level 3: Apply institutional policies and regulations regarding client care and professional decorum while making prudent
decisions NCGENL3E01
Task Description: Evaluates the candidate’s knowledge of and ability to abide by ethical rules of conduct in dealing with patient
Complies with standard operating procedures and Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
work instructions on ethical patient care 3 criteria 3 criteria 3 criteria
As evidenced by:
● Documented Nursing Audit
● Accomplished feedback report
● Summary of Customer Satisfaction
Survey Form
● Performance Evaluation of Superior
● Other forms
Utilizes appropriate documentation of any

interventions involving ethical decision-making
As evidenced by:
● Proper documentation in Nurses’ Note
and Treatment Record Sheet
● Accomplished feedback report
● Other forms
Performs nursing interventions and related patient

care guided by ethical principles and patient rights
As evidenced by:
● Documented witnessed consents
● Documented discussion on patient rights
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Competency Level 3: Maintain availability and functionality of equipment and supplies to meet patient care needs NCGENL3F01
Task Description: Evaluates the candidate’s ability to use, maintain, organize and properly dispose of resources that contribute to the best
nursing care/ services for the patient
Sustains availability and functionality of equipment Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
and supplies 3 criteria 3 criteria 3 criteria
As evidenced by:
● Accomplished inventory report on medical
supplies, medical equipment, and medicines
● Request forms for monthly stocks of
supplies
● Other related documentation
Checks functionality of medical equipment regularly
As evidenced by:
● Records of repair requisitions for
nonfunctioning medical equipment
● Maintenance logbooks of medical
equipment or similar record
● Monitoring tool for equipment and
supplies
Facilitates preventive maintenance and calibration of

existing equipment
As evidenced by:
● Updated calibration stickers of medical
equipment
● Preventive maintenance and calibration
logbooks or similar record
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Competency Level 3: Complete a comprehensive documentation and recording of all data obtained from assessment and care using standard
methods, forms, and protocols, while maintaining confidentiality of the clientNCGENL3G01
Task Description: Evaluates the candidate’s ability to document, store, and make available relevant, accurate and complete data concerning the
patient and patient care in a timely manner using appropriate methods and tools
Applies all standard guidelines and institutional Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
protocols regarding records management 3 criteria 3 criteria 3 criteria
As evidenced by:
● Inquiry of knowledge on institutional
policies on safekeeping, handling,
confidentiality and disposal of records
● Performance Feedback Forms
● No incidences of non-compliance to
recordkeeping policies
Accomplishes all necessary records and forms of

patient/s
As evidenced by:
● Properly and accurately filled-up regular
chart forms and forms for special patient
scenarios
● Accomplished Performance Feedback
Forms
● Patient Monitoring Records
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Compiles completely all forms of patient records to

be submitted to the Medical Records Section as per
institution’s/hospital’s policy
As evidenced by:
● Chart Receiving Logbook between
Nursing Area and Medical Records
department or similar report (e.g.
Nurses’ Report Book)
Forms
Competency Level 3: Participate in the formulation of guidelines and activities of the following: NCGENL3H01
● ISO 9001:2015 (if applicable)
● CQI
● Nursing Service Audit
Task Description: Evaluate the candidate’s ability to constantly practice gathering and using of actual data on patient care for improving care
processes, procedures, standards, and systems
Performs a role in monitoring the continuous quality Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
improvement (CQI) indicators involving nursing 3 criteria 3 criteria 3 criteria
practice
As evidenced by:
● CQI or KPI report monitoring
● Copy of Minutes of the Meeting about
CQI monitoring
Forms
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Performs a role in the regular nursing service audit
As evidenced by:
● Nursing Service Audit monitoring or
similar record
● Copy of Minutes of the Meeting
regarding Nursing Audit
Forms
Attends trainings, seminars and conferences

involving quality improvement and enhancement in
the nursing practice
As evidenced by:
● Proof of training/seminars/conferences
attended which are related to psychiatry
or psychiatric nursing, such as attendance
or certificates
● List of training/seminars/conferences
attended
● Post training activity insight
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Competency Level 3: Practice patient care consistent with safety goals, national laws on health, the Philippine Nursing Act and hospital
policies, rules and regulations NCGENL3I01
Task Description: Evaluates the candidate’s ability to make judgment, decisions and actions in patient care that complies with national laws on
health, the Philippine Nursing Act, and with hospital policies, rules, and regulations, even as appropriate care is provided to the patient
Recognizes policy inconsistencies in patient care Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
practices 3 criteria 3 criteria 3 criteria
As evidenced by:
● Nurses’ Reflection Notes or Nurses’
Diary
● Actual scenario presentation and inquiry
Forms
● Performance evaluation
Possesses skills and knowledge on the institutional

processes involving situations that challenge
compliance with policies and legislations
As evidenced by:
● Actual query of candidate’s judgment
with a sample case scenario
Diary
Forms
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Practices best nursing care in line with local and

national health goals, laws and policies
As evidenced by:
Diary
Form
● Feedback from peers records
Competency Level 3: Participate in a research study that addresses general nursing problems, needs, and issues NCGENL3J01
Task Description: Evaluates the candidate’s application of clinical inquiry, critical thinking, and analysis in nursing practice and the use of
clinically obtained data and information to improve practice
Identifies general nursing problems or issues Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
applicable to current practice 3 criteria 3 criteria 3 criteria
As evidenced by:
● Problem List for Nursing Research
● Research Intention Form or similar
● Nurses’ Reflection Notes
Prepares a study proposal that addresses a general

nursing problem, need or issue
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Identifies general nursing problems or issues

applicable to current practice
As evidenced by:
● Problem List for Nursing Research
● Research Intention Form or similar
● Nurses’ Reflection Notes
Prepares a study proposal that addresses a general

nursing problem, need or issue
Competency Level 3: Delegate appropriate tasks and assignments to staff andallied nursing personnelNCGENL3K01
Task Description: Evaluates the candidate’s ability to provide direction and leadership to lower level personnel and facilitate their learning to
include improvements in care management as well in the management of nursing teams or units
Identifies tasks for patient care to be accomplished Able to accomplish 1 out of Able to accomplish 2-3 out Able to accomplish 4 out of
4 criteria of 4 criteria 4 criteria
As evidenced by:
● Shift Management Reports or similar
records
● Endorsement logbooks/Nurses’ Report
Book
Forms
● Feedback from peers and other personnel
● Nurses’ Reflection Notes/Nurses’ Diary
● Other related documentation and similar
forms used in the institute
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Determines appropriate staff-patient ratio based on

the Patient Classification System
As evidenced by:
records
Book
Forms
● Other related documentation (Primary
Nursing Board, Patient Assignment
Board) and similar forms used in the
institute
Identifies necessary competencies for a specific task
to be accomplished
As evidenced by:
● Actual case scenario presentation and
inquiry of the candidate
● Unit Management Reports or similar
reports
Book
Forms
Communicates goals for task delegation clearly
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As evidenced by:
Forms
Book
Competency Level 3: Participate actively in different professional and personal development programs/activities NCGENL3L01
Task Description: Evaluate the candidate’s ability to demonstrate engagement in continuing education and self-development
Participates actively on programs related to Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
continuing staff development needs 3 criteria 3 criteria 3 criteria
As evidenced by:
● Training Needs Assessment and
Evaluation Form or similar
● Accomplished Personal Development
Forms or similar
● Employee Satisfaction Survey
● Feedback from peers and superiors
Explores development opportunities based on work
P a g e | 32
performance and functions/roles/responsibilities in

the organization
As evidenced by:
● Performance Evaluation or similar
Forms
● Other documentation/proof of
professional developmental
activities/programs attended
Provides active feedback based on improvement in

work performance
As evidenced by:
● Self-feedback Forms
● Consultation notes with peers
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Competency Level 3: Demonstrate professional values and decorum in all aspects of nursing practice NCGENL3M01
Task Description: Evaluate the candidate’s ability to demonstrate critical characteristics and behaviors that a specialist nurse should exhibit as a
role model of expertise, excellent performance, and professionalism
Demonstrates positive work attitude at all times Able to accomplish 1 out of Able to accomplish 2 out of Able to accomplish 3 out of
3 criteria 3 criteria 3 criteria
As evidenced by:
● Commendation letters from peers and
superiors
● Feedback from other personnel
● Customer Satisfaction Survey
Practices work punctuality in all aspects of nursing

practice
As evidenced by:
● No ill records of tardiness/absences
● Accomplished Performance Evaluation
Forms
● Feedback from peers and superiors
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Level 3 Self Assessment Geriatric Nursing 1

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Republic of the Philippines

Self-Assessment Tool for Level 3 Certification in Geriatric Nursing

Name of Candidate: __________________________________________________________________

NICU PICU MICU SICU RR

CCU CVLab Nursery PDU CAPD Clinic

DOH NCP-CAC Self-Assessment Tool (Form 1) P a g e |1

Assesses health history from the patient and family,

● Documented physical examination

Recognizes developmental, age related changes and

Assesses for health promotional and disease

● Documented recommendations which

Correlates CGA results with assessment result for

Identifies acute and chronic health problems and

Refers for acute and chronic health problems and

Secures attachment of clinical evidences (laboratory

Determines polypharmacy; drug interactions and

Evaluates the patient’s and family’s readiness,

Determines the patient’s need for transition to a

Determines the need for advance care plan

● Secure clinical evidences that will support

Recognizes geriatric syndromes and constellations of

Facilitates appropriate use of laboratory, diagnostic

Interprets and utilizes data obtained from the use of

Prioritizes identified problems and needs based on

Formulates individualized nursing care plan which

Develops plan for age-appropriate health screening

Implements plan of care for potential

● Documentation of evidence-based nursing

Implements plan of care for health wellness and

● Demonstration of nursing interventions

Creates an effectivelearning environment

Designs an individualized teaching plan of identified

Formulates individualized teaching plan

Educates patient, family, and caregiver utilizing the

Evaluates the outcomes of health education

Recognizes barriers to communication

Determines common physiological changes

Utilizes therapeutic communication skills applicable

Provides interactive communication with the older

Uses culturally appropriate communication skills

Records pertinent information about the patient

Utilizes the referral system to communicate

Provides clinical information and/or identified

Communicates comprehensive plan of care to

Utilizes appropriate documentation of any

Performs nursing interventions and related patient

Checks functionality of medical equipment regularly

Facilitates preventive maintenance and calibration of

Accomplishes all necessary records and forms of

Compiles completely all forms of patient records to

Performs a role in the regular nursing service audit

Attends trainings, seminars and conferences

Possesses skills and knowledge on the institutional

Practices best nursing care in line with local and

Prepares a study proposal that addresses a general

Identifies general nursing problems or issues

Prepares a study proposal that addresses a general

Determines appropriate staff-patient ratio based on

Communicates goals for task delegation clearly

Explores development opportunities based on work

performance and functions/roles/responsibilities in

Provides active feedback based on improvement in

Practices work punctuality in all aspects of nursing