DOH - SPMS Form 4 Document Code

INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR) Revision No.

Effectivity

I, Grace Ann Porciuncula, of the Nursing Service Division, commit to deliver and agree to be rated on the attainment of the following targets in accordance with the indicated
measures for the period January 1 to June 30, 2020 .

Name of Employee: Grace Ann Porciuncula, RN, MAN Date: December 16, 2019

Approved By: Date: December 20, 2019

Ramoncito C. Magnaye, MD, FPCS, MHA

RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)

Core Functions

100% receiving of admission from Emergency

Ensures faciliation of Admission Process Room, Post Anesthesia Care Unit and from other Station 5 Nursing Staff
clinical departments in our hour from endorsement
100% giving of prescribed medication following the
ensures administration of prescribed
12 rights of medication administration done within Station 5 Nursing Staff
medications ordered by the physician
the shift

Ensures provision of safe and quality

100% assistss in medical and surgical treatment and
nursing care through assissting medical Station 5 Nursing Staff
securing informed consent prior the procedures
and surgical procedures

Ensures provision of safe and quality

100% of radiologic and labaratory examninations
nursing care through facilitations of Station 5 Nursing Staff
were facilitated
radiologic and laboratory examination

100% completion of patient chart within the shift

Ensures completion of patient chart including transcribing of carried out doctors order to Station 5 Nursing Staff
KARDEX and nurse's notes using FDAR method.

100% providing of health education to patients

Ensures Counselling of patients regarding regarding diet, activity, hygiene, exclusive
Station 5 Nursing Staff
health promotion and disease prevention breastfeeding and discharge instructions daily within
the eight hour shift
 RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)

100% facilitations of patients for discharge with

Ensures Facilitations of discharge process Station 5 Nursing Staff
proper home instructions.

Average Rating (Core Functions)

Support Functions

100% soliciting of Client Satisfaction Survey forms

Soliciting of Client Satisfaction Survey
Participation in ISO certifications and
Performance Governance System
acitvities
from discharged patients daily for quality
improvement
100% participating in Quality Audit activities as
scheduled in preparation for ISO certification and
PGS

Attendance to Learning Development 100% attending to at least 1 Learning Development

Intervention Intervention within 6 months

Participation in Training, Awareness and

100% participating in Mother-Baby Friendly
Promotion of Activities in Assigned
Hospital Initiatives Committees activities
Committee

Average Rating (Support Functions)

Strategic Functions

Performance evaluation in Patients' Acquisition of at least 1 unsolicited client positive

/ / /
Commendation Board feedback through commendation board bi-annually

100% active participation in the attainment of DOH

Discharge Turnaround Time mandates on 4 hours discharge turnaround time
/ / /

Continious improvement through

100% participation in quality improvement study
Research

Average Rating (Strategic Functions)

RATING

Final Rating per Function

Percentage Average Rating per Adjectival
Functions (Average Rating x Final Average Rating Remarks
Distribution* Function Rating
Percentage Distribution)

Core Functions 50%

0.00
 RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)
Support Functions 10% 0.00

Strategic Functions 40%

Comments and Recommendation for Development Purposes

Discussed With: Assessed by: Date Final Rating by: Date

I certify that I discussed my assessment of the performance with the
employee

Grace Ann Porciuncula RN, MAN Amor B. Calayan, RN, RM, PhD, MHA Ramoncito C. Magnaye, MD, FPCS, MHA
Nurse I Nurse VII Medical Center Chief II
Employee Supervisor Next Higher Supervisor
Legend: 1- Quality 2 -Efficiency 3 - Timeliness 4 - Average * In the event that there is no strategic output, the percentage distribution is as follows: Core Output - 80% and Support Output - 20%
DOH - SPMS Form 4 Document Code
INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR) Revision No.
Effectivity

I, Grace Ann Porciuncula, of the Nursing Service Division, commit to deliver and agree to be rated on the attainment of the following targets in accordance with the indicated
measures for the period January 1 to June 30, 2020 .

Name of Employee: Grace Ann Porciuncula, RN, MAN Date: December 16, 2019

Approved By: Date: December 20, 2019

Ramoncito C. Magnaye, MD, FPCS, MHA

RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)

Core Functions

100% monitoring performance of staff in rendering

Faciliation of Nursing Care Plan
total nurisng care

100% providing of health information to patients and

their significant others regarding Philhealth
Health Promotion
membership, exclusive breastfeeding and fall
prevention and safety daily

Managements of records thru monitoring 100% checking of in-patient charts' for accuracy,
of in-patients' charts concreteness and completeness daily

Management of resources thru requisition 100% preparing of requisition and issuance form
of medication from Pharmacy for ECART submitted to pharmacy section for ECART medicine
use requests when need arises

Management of resources thru monitoring 100% monitoring of inventory of supplies and

of supplies and equipments availability equipments daily and in monthly basis respectively

Average Rating (Core Functions)

Support Functions
Facilitation of learning gaps through
seminar or trainings
Preparation of Daily Work Assignment
Submission of Daily Ward Census Report
to MCC
100% attending to at least 1 Learning Development
Intervention within 6 months
100% preparing of Daily work Assignment for staff
members'
100% submitting of Daily Ward Census Report to
MCC
 RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)
Participation in Training, Awareness and
100% participating in Mother-Baby Friendly
Promotion of Activities in Assigned
Hospital Initiatives Committees activities
Committee

Average Rating (Support Functions)

Strategic Functions

Performance evaluation in Patients' Acquisition of at least 1 unsolicited client positive

Commendation Board feedback through commendation board monthly

100% active participation in the attainment of DOH

Discharge Turnaround Time
mandates on 4 hours discharge turnaround time

100% submission of documents for specialty

Submission of portfolio for DOH-
nursing under the Nurse Certification Program
NCP
of the Department of Health

Continious improvement through 100% submission of MCC-approved research

Research protocol

Average Rating (Strategic Functions)

RATING

Final Rating per Function

Percentage Average Rating per Adjectival
Functions (Average Rating x Final Average Rating Remarks
Distribution* Function Rating
Percentage Distribution)

Core Functions 50%

Support Functions 10% 0.00

Strategic Functions 40%

Comments and Recommendation for Development Purposes

Discussed With: Assessed by: Date Final Rating by: Date

I certify that I discussed my assessment of the performance with the
employee

Grace Ann Porciuncula RN, MAN Amor B. Calayan, RN, RM, PhD, MHA Ramoncito C. Magnaye, MD, FPCS, MHA
Nurse II Nurse VII Medical Center Chief II
Employee Supervisor Next Higher Supervisor
Legend: 1- Quality 2 -Efficiency 3 - Timeliness 4 - Average * In the event that there is no strategic output, the percentage distribution is as follows: Core Output - 80% and Support Output - 20%
DOH - SPMS Form 4 Document Code
INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR) Revision No.
Effectivity

I, Edward Mendoza, of the Nursing Service Division, commit to deliver and agree to be rated on the attainment of the following targets in accordance with the indicated measures for
the period January 1 to June 30, 2020 .

Name of Employee: Edward Mendoza Date: December 16, 2019

Approved By: Date: December 20, 2019

Ramoncito C. Magnaye, MD, FPCS, MHA

RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)

Core Functions

Monitoring of Vital Signs and Intake and 100% monitoring of vital signs and intake and output
Output accurately

100% collecting of specimen and sending to

Collection and Submission of Specimen
laboratory as necessary

100% forwarding of necessary documents contained

Discharge Process in patient's chart to Billing Section daily after
doctor's rounds

100% documenting of accurate and complete vital

Management of records thru signs, fetal heart tone, intake and output and other
documetation pertinent data regarding patient care daily within the
shift

Management of resources thru counting 100% checking for completeness and functionality of
and checking of supplies, articles and equipments and articles and inventory of supplies
equipment every shift

Management of resources thru requisition 100% requesting of supplies stocked in the ward thru
of supplies from CSR E-request per HOMIS

Average Rating (Core Functions)

Support Functions
 RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)
100% soliciting of Client Satisfaction Survey forms
Soliciting of Client Satisfaction Survey from discharged patients daily for quality
improvement

Attendance to Learning Development 100% attending to at least 1 Learning Development

Intervention Intervention within 6 months

Average Rating (Support Functions)

Strategic Functions

Performance evaluation in Patients' Acquisition of at least 1 unsolicited client positive

Commendation Board feedback through commendation board monthly

100% active participation in the attainment of DOH

4 hours Discharge Turnaround Time
mandates on 4 hours discharge turnaround time

Average Rating (Strategic Functions)

RATING

Final Rating per Function

Percentage Average Rating per Adjectival
Functions (Average Rating x Final Average Rating Remarks
Distribution* Function Rating
Percentage Distribution)

Core Functions 50%

Support Functions 10% 0.00
Strategic Functions 40%
Comments and Recommendation for Development Purposes
Discussed With: Assessed by: Date Final Rating by: Date
I certify that I discussed my assessment of the performance with the
employee

Edward Mendoza Amor B. Calayan, RN, RM, PhD, MHA Ramoncito C. Magnaye, MD, FPCS, MHA
Nursing Attendant II Nurse VII Medical Center Chief II
Employee Supervisor Next Higher Supervisor
Legend: 1- Quality 2 -Efficiency 3 - Timeliness 4 - Average * In the event that there is no strategic output, the percentage distribution is as follows: Core Output - 80% and Support Output - 20%
DOH - SPMS Form 4 Document Code
INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR) Revision No.
Effectivity

I, Charlene Castillo, of the Nursing Service Division, commit to deliver and agree to be rated on the attainment of the following targets in accordance with the indicated measures for
the period January 1 to June 30, 2020 .

Name of Employee: Charlene Castillo, RN, MAN Date: December 16, 2019

Approved By: Date: December 20, 2019

Ramoncito C. Magnaye, MD, FPCS, MHA

RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)

Core Functions

100% receiving of admission from Emergency

Faciliation of Admission Process Room, Post Anesthesia Care Unit and from other
clinical departments in our hour from endorsement

100% giving of prescribed medication following the

Administration of prescribed medications
12 rights of medication administration done within
ordered by the physician
the shift

Provision of safe and quality nursing care

100% assistss in medical and surgical treatment and
through assissting medical and surgical
securing informed consent prior the procedures
procedures

Provision of safe and quality nursing care

100% of radiologic and labaratory examninations
through facilitations of radiologic and
were facilitated
laboratory examination

100% completion of patient chart within the shift

Management of records through
including transcribing of carried out doctors order to
completion of patient chart
KARDEX and nurse's notes using FDAR method.

100% facilitations of patients for discharge with

Facilitations of discharge process
proper home instructions.

Average Rating (Core Functions)

Support Functions
 RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)
100% soliciting of Client Satisfaction Survey forms
Soliciting of Client Satisfaction Survey from discharged patients daily for quality
improvement
Attendance to Learning Development 100% attending to at least 1 Learning Development
Intervention Intervention within 6 months

Average Rating (Support Functions)

Strategic Functions

Performance evaluation in Patients' Acquisition of at least 1 unsolicited client positive

/ / /
Commendation Board feedback through commendation board every month

100% submission of documents for specialty

Submission of portfolio for DOH-
nursing under the Nurse Certification Program
NCP
of the Department of Health

100% active participation in the attainment of DOH

Discharge Turnaround Time / / /
mandates on 4 hours discharge turnaround time

Continious improvement through 100% submission of MCC-approved research

Research protocol

Average Rating (Strategic Functions)

RATING

Final Rating per Function

Percentage Average Rating per Adjectival
Functions (Average Rating x Final Average Rating Remarks
Distribution* Function Rating
Percentage Distribution)

Core Functions 50%

Support Functions 10% 0.00

Strategic Functions 40%

Comments and Recommendation for Development Purposes

Discussed With: Assessed by: Date Final Rating by: Date

I certify that I discussed my assessment of the performance with the
employee

Charlene Castillo RN, MAN Amor B. Calayan, RN, RM, PhD, MHA Ramoncito C. Magnaye, MD, FPCS, MHA
Nurse I Nurse VII Medical Center Chief II
Employee Supervisor Next Higher Supervisor
 RATING
Success indicator Remarks/Justification
Output Actual Accomplishment Q E T A s of Unmet Targets
(Target + Measure)
(1) (2) (3) (4)
Legend: 1- Quality 2 -Efficiency 3 - Timeliness 4 - Average * In the event that there is no strategic output, the percentage distribution is as follows: Core Output - 80% and Support Output - 20%