Republic of the Philippines DEPARTMENT OF HEALTH …ejobs.doh.gov.ph/ncp-update/pdf/MCN/Level 4 Self Assessment... · DOH NCP-CACSelf-AssessmentTool(Form 1) Revision0,April2013 Page|1

Republic of the PhilippinesDEPARTMENT OF HEALTH

NURSE CERTIFICATION PROGRAM

DOH NCP-CAC Self-Assessment Tool (Form 1)Revision 0, April 2013

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Self-Assessment Tool for Level 4 Certification in Maternal and Child Health Nursing

Name of Candidate: __________________________________________________________________

Hospital of current employment: ________________________________________________________

Introduction: A nurse Candidate who seeks to be certified as a specialist in Maternal and Child HealthNursing, Level 4, will have to accomplish this self-assessment form and prepare the needed evidence toshow proof of competence. Upon accomplishment of the form, the candidate will discuss the data and theevidence with his/her immediate supervisor for validation. It may be necessary to revise responsesbased on this discussion. The Candidate then submits to the Committee on Assessment and Certificationthe validated self-assessment tool and supporting evidence for review and assessment by the independentAssessors, who will determine competency or recommend development opportunities.

This Self-Assessment Tool is both formative and summative. As such it provides information as to theareas and levels of competency of the Candidate with respect to the standard performance criteria. It alsoinforms on competency gaps and therefore provides the Candidate with leads on which learning anddevelopment interventions he/she should undertake.

Instructions: The first column in the table lists behavioural indicators that determinesuccessful/outstanding performance in the workplace. In order to provide a calibrated picture of theCandidate’s proficiency at demonstrating these behaviors, the tool uses a three-point rating scale thatindicates 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 ImmediateSupervisor, with the accompanying evidence to prove statements of competence. In your respectivespecialty 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 currentlyassigned (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



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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 standrads:Satisfactory, Very Satisfactory, Outstanding.

Competency Level 4: Identify high-risk patient’s problems based on the assessment NCMCNL4A01Task Description: Evaluates the candidate’s ability to evaluatethe patient for the purpose of identifying actual and/or potential nursingproblem/s to serve as basis in planning patient care

Criteria Satisfactory Very Satisfactory OutstandingIdentifies high-risk pregnancy complications

As evidenced by:● Documented assessment on cases of

placenta previa, abruption, pre-eclampsia,etc.

● Patient’s High-risk Assessment Record orsimilar entry

● Documentation in Nurses’ ProgressNotes

● Other documentation/forms

Identifies presence of criteria for high-riskpregnancyAs evidenced by:

● Documented assessment on cases ofplacenta previa, abruption, pre-eclampsia,etc.

● Patient’s High-risk Assessment Record orsimilar entry



Able to accomplish 1 out of3 criteria





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Facilitates additional diagnostic tests needed forhigh-risk woman

As evidenced by:● Accomplished diagnostic tests for high-

risk woman (i.e. OGTT, congenitalanomaly scan, Alpha-Feto Protein test,amniocentesis, bio-physical profile,thyroid function test)



Competency Level 4: Plan a range of nursing care strategies and approaches to ensure continuity of care to high risk pregnant womanNCMCNL4A02Task Description: Evaluates the ability of the candidate to formulate nursing care plan parallel to and in support of medical care

Criteria Satisfactory Very Satisfactory OutstandingDevelops a plan of care based on the priorityproblems of an actual high risk pregnant womanAs evidenced by:

● Accomplished Nursing Care Plan● Documentation in Nurses’ Progress

Notes● Other documentation

Formulates a plan of care based on a given scenarioAs evidenced by:


Notes● Patient’s Problem List● Other means






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Formulates plan of care based on the other needs ofthe patient (i.e. nutrition, physical mobility,immunization)

As evidenced by:

● Nursing Care Plan● Documentation in Nurses’ Progress

Notes● Other documentation

Competency Level 4: Develop an adaptive care plan for problems related to high-risk pregnant patients NCMCNL4A03Task Description: Evaluates ability of the candidate to implement and consequently modify nursing care plan depending on outcomes andresponse of patient to treatment and care

Criteria Satisfactory Very Satisfactory OutstandingAnticipates possible adverse reactions ofmedications being administered through thefollowing:

1. Enumerating the adverse reactions ofmedication being administered

2. Maintaining safe administration of medicationand other therapeutics to highrisk pregnant woman3. Initiating initial management on identified

possible adverse effectsAs evidenced by:


Notes● Adverse Drug Reactions Monitoring or

similar entry● Other documentation/form

Able to accomplish 1-3 outof 7 criteria





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Identifies problems on high risk pregnancy based onmonitoring results such as:

1. Elevation of blood pressure2. Fetal bradycardia/tachycardia3. Prolonged labor4. Meconium stains5. BOW ruptured

As evidenced by:● Accomplished Nursing Care Plan● Documentation in Nurses’ Progress

Notes● Other documentation or records

Handles safe normal delivery and assists in thedelivery of high risk pregnancy by performing thefollowing:

1. Identification of the mechanism of Labor /Cardinal movement

2. Proper breathing technique3. Proper delivery techniques4. Perineal support using Ritgen’s Maneuver5. Checking of completeness of the placenta6. Identification of laceration

As evidenced by:● Accomplished Nursing Care Plan● Actual demonstration● Documentation in Nurses’ Progress

Notes● Performance Feedback Form report● Other documentation or records



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Performs advanced suturing techniques and assists inthe management of high risk pregnancy byperforming the following:

1. Advanced suturing techniques such asInverted T ,Subcuticular and figure of 8

2. Identification of other associated high riskproblems relating to laceration and suturing(i.e. hematoma)

3. Identified problem correlatedAs evidenced by:

● Accomplished Nursing Care Plan● Actual performance and demonstration● Documentation in Nurses’ Progress


Assists in newborn resuscitation through thefollowing:

1. Identification and provision of necessarydevices in neonatal resuscitation

2. Assurance that all devices are available andfunctioning on emergency situation

3. Performance of infection control measures inassisting in resuscitation procedure

As evidenced by:● Accomplished Nursing Care Plan● Actual performance and demonstration● Documentation in Nurses’ Progress




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Addresses specific lactation problems by performingthe following:

1. Identification of lactation problems (i.e.inverted nipples, insufficient milk, baby’scongenital anomalies, poor suck, sorenipples)

2. Planning of a range of action to address theidentified problem

3. Implementation of the plan of action andevaluation of its output



Anticipates postpartum complications to initiatepossible nursing interventions by performing thefollowing:

1. Identification of postpartum complications(i.e. hemorrhage, uterine bleeding/atony,hematoma, retained placental products)

2. Initiation of independent nursing actionbased on complications identified

3. Evaluation of independent nursing actionsdone





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Competency Level 4: Analyze effectiveness of nursing management to high risk pregnant woman NCMCNL4A04Task Description: Evaluates the candidate’s ability to monitor and assess outcomes of care, and formulate recommendations

Criteria Satisfactory Very Satisfactory OutstandingIdentifies rooms for improvement in the nursing careplan of the high risk pregnant woman

As evidenced by:● Documentation in Nurses’ Progress

Notes● Accomplished Nursing Care Plan● Other documentation or records

Discusses evaluation of a high-risk pregnant womanthrough a sample case scenario

As evidenced by:● Documentation Nurses’ Progress Notes● Accomplished Nursing Care Plan● Sample case scenario presentation

Reflects feedbacks from patients, colleagues,superiors and doctors with regards to nursing plan ofcare

As evidenced by:● Feedback forms● Patient’s Satisfaction Survey report● Performance and peer evaluation● Other documentation






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Competency Level 4: Conduct health education class/program to identified clients NCMCNL4B01Task Description: Evaluates the candidate’s ability to provide patient-specific and additional information relevant to promotion of health,prevention and continuing care

Criteria Satisfactory Very Satisfactory OutstandingUtilizes goal-directed activities to a group ofpregnant womenAs evidenced by:

● Health education program documentation● Accomplished Health Teaching Plans● Documentation in Nurses’ Progress Notes● Patient Satisfaction Survey● Performance Feedback Form report● Other documentation

Prepares proper educational tools such as visual aids,journals, pamphlets,audio-visual materials,brochures, etc.As evidenced by:

● Accomplished Health Teaching Plan● Actual health teaching materials● Documentation in Nurses’ Progress Notes● Performance Feedback Form report● Other documentation

Develops a conducive environment for teaching-learning activitiesAs evidenced by:

● Health Teaching Plan● Topics Layout or similar record● Accomplished Nursing Care Plan● Documentation in Nurses’ Progress

Notes● Performance Feedback Form report● Other documentation

Able to accomplish 1 outof

3 criteria





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Competency Level 4: Answer queries from the client and family NCMCNL4C01Task 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 outcomesCriteria Satisfactory Very Satisfactory Outstanding

Demonstrates interpersonal skills in sustainingsupport from the client and family


Notes● Patient Satisfaction Survey report● Sample case scenario presentation● Nurses’ Reflection Notes● Other documentation

Answers questions with timely and accurateinformation about the patient’s condition



Establishes a therapeutic professional relationshipthroughout any nurse-patient interaction






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Competency Level 4: Coordinate accordingly with other members of the healthcare team regarding client care NCGENL4D01Task Description: Evaluates the ability of the candidate to contribute to the services, decisions and actions of the healthcare team in deliveringcare to the patient

Criteria Satisfactory Very Satisfactory OutstandingGives recommendations for plan of action duringteam meetings/conferencesAs evidenced by:

● KARDEX/Nursing Care Plan● Copy of minutes of the meeting● Other means/forms

Acts as the representative of the nursing serviceduring multidisciplinary discussions and activitiesAs evidenced by:

● Documentation in Nurses’ Note andTreatment Record Sheet● Accomplished Nursing Care Plan● Evaluation in Performance Feedback Form● Copy of Minutes of the Meeting● Other means of documentation

Attends in multidisciplinary meetings concerningpatient’s welfareAs evidenced by:

● Copy of Minutes of the Meeting● Other means

Able to accomplish 1 outof

3 criteria





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Competency Level 4: Analyze situations and guide clients and significant others in making decisions in response to ethical issues concerningpatient care (Discharge Against Medical Advice or DAMA, Transfer to Hospital Of Choice or THOC, etc.)NCGENL4E01Task Description: Evaluates the candidate’s knowledge of and ability to abide by ethical rules of conduct in dealing with patient

Criteria Satisfactory Very Satisfactory OutstandingMaintains compliance of client-related actions to thestandard operating procedures and work instructionsof the institution

As evidenced by:● Documentation in Nurses’ Note and

Treatment Record Sheet● No records of non-conformance/Staff 201

file

Conforms duly to hospital protocol when respondingto patient concerns requiring immediate ethicaldecision-makingAs evidenced by:

● Accomplished forms on hospital protocolcompliance

● Documentation of response to patientconcerns

● Properly secured informed consent/waiver which includes:○ Procedure○ Relationship to patient○ Name, Signature of Patient/Guardian

and Witness○ Date/Time Consent has been signed

● Other forms



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Utilizes appropriate institutional documentation of allinterventions and care done involving ethical judgment

As evidenced by:● Documented witnessed consents● Summary of Customer Satisfaction

Survey● Documentation in Nurses’ Note and

Treatment Record Sheet● Case Study/Situational Analysis● Other means of documentation

Competency Level 4: Anticipate needed medical supplies, medical equipment, drugs and medicines NCGENL4F01Task Description: Evaluates the candidate’s ability to use, maintain, organize and properly dispose of resources that contribute to the bestnursing care/ services for the patient

Criteria Satisfactory Very Satisfactory OutstandingAnalyzes critical level of medical supplies, drugsand medicines

As evidenced by:● Analysis report on critical level of

medical supplies, drugs, and medicines● Reports on preventive maintenance of

medical equipment● Accomplished replenishment slips● Other related documentation






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Monitors preventive maintenance of medicalequipment as scheduled

As evidenced by:● Accomplished preventive maintenance

forms● Schedule list of equipment requiring

preventive maintenance● Monitoring logbook for preventive

maintenance or similar● Other related documentation

Accomplishes needed requisition process/es toanticipate needed equipment and/or supplies

As evidenced by:● Accomplished requisition slips for

needed supplies and equipment● Report on needed supplies and/or

equipment for the area● Other related documentation



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Competency Level 4: Formulate measures for continuous quality improvement on current systems and policies pertaining to recordsmanagement NCGENL4G01Task Description: Evaluates the candidate’s ability to document, store, and make available relevant, accurate and complete data concerning thepatient and patient care in a timely manner using appropriate methods and tools

Criteria Satisfactory Very Satisfactory OutstandingPerforms chart and record checking based on thefollowing criteria: completeness, accuracy, properlylabelled, traceability, easily retrievable, availabilityin point of use, legibility and proper correction oferroneous entry

As evidenced by:● Chart Review Logbooks and Monitoring

or similar logbook● Inquiry on knowledge of chart lapse

review protocol based on institutionalpolicies

● Accomplished Performance FeedbackForms

● Other related documentation

Implements corrective actions on proper recordsmanagement

As evidenced by:● Analysis of actual scenario● Chart Review Logbooks and Monitoring

or similar logbook● Accomplished Performance Feedback

Forms






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Recommends revision of forms, procedures andwork instructions on records management

As evidenced by:● Revision recommendation letters on

forms, procedures and/or workinstructions



Competency Level 4: Implement guidelines and activities of the following: NCGENL4H01● 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 careprocesses, procedures, standards, and systems

Criteria Satisfactory Very Satisfactory OutstandingFormulates recommendations to address non-conformities or problems related to CQI monitoring

As evidenced by:● CQI monitoring reports/KPI● Non-conformance reports (if applicable)● Recommendation letters for

preventive/corrective actions or CPIAR● Other related documentation

Implements corrective actions for improvement in






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quality patient care based on audit results

As evidenced by:● Recommendation letters for

preventive/corrective actions or CPIAR● Minutes of the Meeting regarding nursing

audit● Non-conformance reports (if applicable)● Other related documentation

Recommends to translate feasible identifiedsolutions into quality procedures or processes

As evidenced by:● Quality Procedure/Process Registration

Forms or similar form/s● Copy of Minutes of the Meeting

involving quality improvement andassurance



Competency Level 4: Recommend Plan of Action on identified nursing issues NCGENL4I01Task Description: Evaluates the candidate’s ability to make judgment, decisions and actions in patient care that complies with national laws onhealth, the Philippine Nursing Act, and with hospital policies, rules, and regulations, even as appropriate care is provided to the patient

Criteria Satisfactory Very Satisfactory OutstandingRecognizes relevant issues concerning patient carethat are not in line with acknowledged institutionalpolicies and local/national guidelines






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As evidenced by:● Actual scenario presentation and inquiry● Nurses’ Reflection Notes/ Nurses’ Diary● Accomplished Performance Feedback

Forms● Other related documentation

Proposes a plan of action to address the relevantissues recognized with the following criteria:reliable, appropriate, clearly stated and applicable

As evidenced by:● Drafted plans and proposals regarding

issues and concerns● Recommendation letters for incident

reviews● Nurses’ Reflection Notes/ Nurses’ Diary● Accomplished Performance Feedback

Forms● Other related documentation

Monitors the implementation of action plansrecommended to resolve patient care issues

As evidenced by:● Monitoring and observation reports● Nurses’ Reflection Notes/ Nurses’ Diary● Accomplished Performance FeedbackForms● Other related documentation



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Competency Level 4: Conduct research study that addresses problems, needs and issues relevant to nursing specialty NCGENL4J01Task Description: Evaluates the candidate’s application of clinical inquiry, critical thinking, and analysis in nursing practice and the use ofclinically obtained data and information to improve practice

Criteria Satisfactory Very Satisfactory OutstandingIdentifies specialty nursing problems or issuesapplicable to current practice

As evidenced by:● Problem List for Nursing Specialty

Research● Research Intention Form or similar● Other related documentation

Prepares a study proposal that addresses a specialtynursing problem, need or issue

As evidenced by:● Actual proposal of a specialty nursing

study● Study proposal documents● Other related documentation

Facilitates in a research study addressing a specialtynursing problem, need or issue

As evidenced by:● Implementation schedule of specialty

study● Actual study documents● Other related documentation






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Competency Level 4: Supervise the delegations of tasks at appropriate level and assignments NCGENL4K01Task Description: Evaluates the candidate’s ability to provide direction and leadership to lower level personnel and facilitate their learning toinclude improvements in care management as well in the management of nursing teams or units

Criteria Satisfactory Very Satisfactory OutstandingSets deadline on assigned tasks

As evidenced by:● Shift Management Reports or similar● Task Progress Monitoring Reports or

similar● Endorsement logbooks● Accomplished Performance Feedback

Forms● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation and similar

forms used in the institute

Monitors closely progress of assigned tasks per shift

As evidenced by:● Shift Management Reports or similar● Task Progress Monitoring Reports or

similar● Endorsement logbooks/Nurses’ ReportBook● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation (Key

performance indicators, etc.) and similarforms used in the institute






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Provides right direction and guidelines on patientcare to personnel

As evidenced by:● Accomplished Personnel Evaluation

Reports● Unit Management Reports● Endorsement logbooks● Feedback from peers and personnel● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation and similar


Evaluates performance of assigned personnel afterthe task has been completed

As evidenced by:● Accomplished Personnel Evaluation

Reports● Consultation logs with personnel or

similar● Endorsement logbooks● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation and similar




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Competency Level 4: Conduct lectures and act as resource person to different nursing courses as part of professional & personal developmentNCGENL4L01Task Description: Evaluate the candidate’s ability to demonstrate engagement in continuing education and self-development

Criteria Satisfactory Very Satisfactory OutstandingContributes to continuous learning by being aresource speaker or preceptor at least 4 times perannumAs evidenced by:● Certificates of Recognition as Speaker/Lecturer● Certificate of Attendance● Program Activities with assigned topics of lectures● Evaluation Results as Lecturer● Top Evaluation Results● Other related documentation

Participates in the formulation of program careerpathways for nurses at least 3 times per yearAs evidenced by:● Attendance on Career path/Staff development

Meetings● Minutes of the Meeting● Actual career program plans for staff

development● Other related documentation

Attends continuous professional development atleast on the thesis proposal levelAs evidenced by:● School Registration to Postgraduate degree● Thesis Proposal Manuscript● Other related documentation






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Competency Level 4: Monitor professional and personal decorum at all levels of nursing personnel within the standards of nursing practice thatprovides motivation and allows growth & productivity NCGENL4M01Task Description: Evaluate the candidate’s ability to demonstrate critical characteristics and behaviors that a specialist nurse should exhibit as arole model of expertise, excellent performance, and professionalism

Criteria Satisfactory Very Satisfactory OutstandingSupervises peers on proper decorum whenperforming patient careAs evidenced by:

● Accomplished Performance Feedbackforms

● Peer Evaluation Reports● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation

Advises peers regarding work professionalism andpunctuality throughout their nursing practiceAs evidenced by:

● Accomplished Performance Feedbackforms

● Peer Evaluation Reports● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation

Obtains recognition and awards based onprofessional duty and practice

As evidenced by:● Certificates of Awards/Recognitions● Records of nomination for particular

recognition awards● Other related documentation




Documents

Republic of the Philippines DEPARTMENT OF HEALTH …ejobs.doh.gov.ph/ncp-update/pdf/MCN/Level 4 Self Assessment... · DOH NCP-CACSelf-AssessmentTool(Form 1) Revision0,April2013 Page|1