Republic of the Philippines DEPARTMENT OF HEALTH NURSE ...ejobs.doh.gov.ph/ncp-update/pdf/REN/Level...

Republic of the PhilippinesDEPARTMENT OF HEALTH

NURSE CERTIFICATION PROGRAM

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

P a g e | 1

Self-Assessment Tool for Level 4 Certification in Renal Nursing - Hermodialysis

Name of Candidate: __________________________________________________________________

Hospital of current employment: ________________________________________________________

Introduction: A nurse Candidate who seeks to be certified as a specialist in Renal Nursing, Level 4,will have to accomplish this self-assessment form and prepare the needed evidence to show proof ofcompetence. Upon accomplishment of the form, the candidate will discuss the data and the evidence withhis/her immediate supervisor for validation. It may be necessary to revise responses based on thisdiscussion. The Candidate then submits to the Committee on Assessment and Certification the validatedself-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 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



P a g e | 2

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 4: Secure complete history of patients undergoing Hemodialysis (HD) treatment NCRENL4HDA01Task Description: Evaluates the candidate’s ability to evaluate the patient for the purpose of identifying actual and/or potential nursingproblem/s to serve as basis in planning patient care

Criteria Satisfactory Very Satisfactory OutstandingFills up Patient Data Sheet (PDS) or equivalentform completely (according to institution’s policy)As evidenced by:

● Completed Patients Data sheet● Completed HD treatment flow sheet● Completed Nurse’s Progress Notes, Nursing

Care Plan or other applicable record in theinstitution where needed data may be verifiedand validated

● Correct answers to case analysis● Completed procedure checklist by the

assessor

Checks for the completeness of HD prescription

As evidenced by:● Identifying components of HD order

a. Frequencyb. Durationc. Anticoagulationd. Blood Flow Rate (BFR)e. Dialysate Flow Rate (DFR)f. Estimated Dry Weight (EDW) (if

specified)

Able to accomplish 1-2 outof 5 criteria


Able to accomplish 5 out of5 criteria



P a g e | 3

g. Ultra-filtration (UF) ordered beforestarting the treatment

● Explanation per component of HD order● Completed Hemodialysis Treatment Sheet

Assesses patient’s vascular access

As evidenced by:Arteriovenous Fistula (AVF) and ArteriovenousGraft (AVG)

● Inspecting for the physical appearance of thesite. (Checks the site redness, swelling,hematoma and temperature of the access)

● Assessing for presence of thrill throughpalpation.

● Assessing for presence of bruit throughauscultation

● Completed hemodialysis treatment sheet

Central Venous Catheters (CVC)● Inspecting for the physical appearance of the

catheter site. (Assesses for the central venouscatheter (CVC) site for redness, swelling,pus, odor and thetemperature of the site)

● Checking for the patency of the catheterlimbs




P a g e | 4

Identifies pre hemodialysis complications

As evidenced by:● Assessing for signs of fluid overload

(dyspnea, rales, distended jugular vein andedema)

● Assessing for signs of infection (fever, chills,feeling of coldness at home or duringtreatment)

● Assessing for signs of bleeding (gumbleeding, menstruation (female), stool,bloody urine for patients with residual renalfunction)


Assesses patient according to the level of priority(according to institutions policy)

As evidenced by:● Defining of prioritization level of HD

patients● Enumeration of sample cases per level of

priority● Correct answer to case analysis● Completed HD treatment sheet



P a g e | 5

Competency Level 4: Refer to physician using the Situation-Background-Assessment-Recommendation (SBAR) methodologyNCRENL4HDA02Task Description: Evaluates the candidate’s ability to evaluate the patient for the purpose of identifying actual and/or potential nursingproblem/s to serve as basis in planning patient care

Criteria Satisfactory Very Satisfactory OutstandingUtilizes SBAR method in referral

As evidenced by:● Documentation in Nurses Progress Notes● Record of SBAR referral reports

Identifies the Situation

As evidenced by:● Correctly identified the name of the nurse,

area and room number, name of patient andproblem

● Documentation of assessment data● Documentation Nurses Progress Notes● Record of SBAR referral reports






P a g e | 6

Ascertains the background

As evidenced by:● Correctly identified attending physician,

admitting diagnosis, circumstances leading tosituation, relevant known facts

● Record of SBAR referral reports● Timeliness of the referral observed

Performs the necessary assessment

As evidenced by:● Documentation of assessment data● Documentation of intervention/s to addressproblem, reports independent interventions

done● Timeliness of the referral observed

Reports independent interventions

As evidenced by:● Documentation of independent interventions

in the Nurses Progress Notes● Documentation of intervention/s to address

problem, reports independent interventionsdone

● Documented timeliness of the referral observed



P a g e | 7

Competency Level 4: Formulate nursing diagnosis/es focusing on patients undergoing HD treatment (conventional HD or Continuous RenalReplacement Therapy) including complications NCRENL4HDA03Task Description: Evaluates the candidate’s ability to evaluate the 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 focus according to prioritizationAs evidenced by:

● Correct answers to case analysis andrationale (at least 2 cases)

● Documentation on Nurses Progress Notes● Documentation on hemodialysis treatment

sheet.Identifies subjective and objective data supportingfocusAs evidenced by:

● Identification of subjective data● Identification of objective data● Documentation on Nurses Progress Notes

Identifies independent, interdependent anddependent nursing interventions addressing focusAs evidenced by:

● Classification of interventions: independent,interdependent and dependent

● Properly carried out doctors’ orders● Timely implementation of interventions

Identifies patient response to nursing/medicalintervention renderedAs evidenced by:

● Correctly identified patient response● Correct answers to case analysis and

rationale● Documentation on Nurses’ Progress Notes






P a g e | 8

Competency Level 4: Identify critical value and interprets pertinent specific laboratory and diagnostic results of patient undergoinghemodialysis treatment and managementNCRENL4HDA04Task Description: Evaluates the candidate’s ability to evaluate the 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 routine blood examinations for patientsundergoing HDAs evidenced by:

● Documentation on Nurses’ Progress Notes● Other forms

Organizes requirements prior to hemodialysislaboratory monitoring every 6 months (HepatitisProfile: HbsAg, Anti Hbs, Anti HCV)As evidenced by:

● Documentation on Nurses’ Progress Notes● Other forms

Classifies pre hemodialysis laboratory (CBC,Creatinine, BUN, Potassium, Calcium, Phosphorus,

Lipid Profile, Albumin, ALT, Ferritin)As evidenced by:

● Documentation on Nurses’ Progress Notes● Accomplished referral forms● Other forms

Identifies low and high valuesAs evidenced by:

● Documentation on Nurses’ Progress Notes● Accomplished referral forms● Other forms






P a g e | 9

Correlates laboratory results with presenting signsand symptomsAs evidenced by:

● Correctly identified patient response● Correct answers to case analysis and

rationale● Documentation on Nurses’ Progress Notes



P a g e | 10

Competency Level 4: Identify plan of care according to the prioritized needs of Hemodialysis patientsNCRENL4HDA05Task Description: Evaluates the ability of the candidate to formulate nursing care plan parallel to and in support of medical care

Criteria Satisfactory Very Satisfactory OutstandingAccomplishes planning activitiesAs evidenced by:

● Copy of activity plan● Attendance registry of facilitated

demonstration● Evaluation records

Documents assessment specified objective andsubjective dataAs evidenced by:

● Documentation in Nurses Notes● Other forms

Conducts long and short term planAs evidenced by:


Documentation of intervention/s that directly relateto the objective/sAs evidenced by:


Identifies correct rationale for intervention/sAs evidenced by:







P a g e | 11

Competency Level 4: Identify proper personnel protective equipment before initiating HD according to protocol NCRENL4HDA06Task 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 OutstandingPuts on 4 Personal Protective Equipment (PPEs) :Face shield/goggles, Mask, Gloves, GownAs evidenced by:

● Results of direct observation by the assessor● Correct Placement of PPEs● Explains the importance and purpose of each

PPEs

Able to accomplish 1 out of3 evidences



Competency Level 4: Prepare vascular access NCRENL4HDA07Task 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 Outstanding

Performs cannulation of Arteriovenous Fistula(AVF) and Arteriovenous Graft (AVG)

As evidenced by:● Completed competency assessment tool for

cannulating AVG and AVF. (see attachedprocedure checklist, 17 criteria)

Central Venous Catheters (CVC)● Completed competency assessment tool for

central venous catheters. (see attachedprocedure checklist, 21 criteria)

Able to accomplish _ out of17 criteria








P a g e | 12

Competency Level 4: Resolve the recognized possible vascular access complications according to protocol NCRENL4HDA08Task 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 OutstandingIdentifies complications associated to cannulation ofArteriovenous Fistula (AVF) and ArteriovenousGraft (AVG)As evidenced by:

● Identification of any of the ff as applicable:-Infiltration-Pain-Clotted site-Difficult to cannulate (more than 3 attemptsin one site)-No bruit-No thrill

● Completed HD treatment flow sheet● Complete Nurse’s Progress Notes, Nursing


Determines appropriate action to address theidentified AVF / AVG - related complicationsAs evidenced by:

● Performed interventions particular toidentified problem based on the existingclinical pathway (if applicable)

● Completed HD treatment flow sheet● Completed Nurse’s Progress Notes, Nursing







P a g e | 13

Identifies complications associated to central venouscathetersAs evidenced by:

● Identification of any of the ff as applicable:-Infection (redness, pus, tenderness at theaccess site, fever)-Bleeding / leak in the CVC site-Poor outflow / inflow (clotted)

● Completed HD treatment flow sheet● Complete Nurse’s Progress Notes, Nursing


Determines appropriate action to address theidentified CVC - related complications

As evidenced by:

● Performed interventions particular toidentified problem based on the existingclinical pathway (if applicable)

● Completed HD treatment flow sheet● Completed Nurse’s Progress Notes, Nursing




P a g e | 14

Competency Level 4: Administer prescribed medications pre, intra and post HD according to protocol NCRENL4HDA09Task Description: Evaluates ability of the candidate to implement and consequently modify nursing care plan depending on outcomes andresponse of patient to treatment and care


Performs medication administration as follows:

Pre HD (given before the start of the treatment canbe given directly to the access if intravenous site isrequired)

As evidenced by:● Results of direct observation by the assessor.● Completed medication sheet● Completed HD treatment flow sheet● Completed Nurse’s Progress Notes, Nursing


Intra HD (during the treatment, can be given directlyto the venous injection port of the bloodline)








P a g e | 15

Post HD (after the treatment it can be given in thevenous injection port before blood will be returnedor after the reinfusion of blood directly into thepatients access)



Competency Level 4: Monitor and resolve recognized possible intra – dialysis complicationsNCRENL4HDA10Task 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 OutstandingChecks patient every 30 minutes or more frequentlyfor hemodynamically unstable patients

As evidenced by:● Accomplished evaluation by the assessor per

observation● Completed Hemodialysis flow sheet● Completed Nurse’s Progress Notes, Nursing







P a g e | 16

Implements independent nursing interventions toresolve identified complications according toinstitution’s protocolAs evidenced by:

● Completed Checklist on independent nursingintervention which includes:

Identification of 9 complications and interventions:1. Hypotension

-Turns off Ultra filtration (UF)-Places patient in modified Trendelenburgposition-Checks Capillary Blood Glucose (CBG)-Implements fluid challenge of 100ml-Rechecks Blood Pressure after 15 minutes-Refers to attending physician using SBARmethodology

2. Chills-Checks for the temperature of patient anddialysate-Provides heating pad/extra blanket-Assesses for the access site for possibleinfection, or other factors that may contributeto patients condition-Refers to attending physician using SBARmethodology

3. Hypertension-Assesses for signs and symptoms such as(headache, dizziness, flushing and nape pain)-Places patient in a high fowlers position-Reviews patients medication list-Refers to attending physician using SBARmethodology



P a g e | 17

4. Cramps-Turns off / adjusts Ultra filtration (UF)-Performs dorsi-flexion on the affectedextremity-Checks for the latest electrolytes of patient-Implements fluid challenge of 100ml-Refers to attending physician using SBARmethodology

5. Chest pain-Turns off / adjusts Ultra filtration (UF)-Decreases the blood flow rate (BFR)-Assesses using the P(provokes) Q (quality)R (radiates) S (severity) T (time) guide-Refers to attending physician using SBARmethodology-Administers oxygen of 2l/min as necessary

6. Seizure-Establishes safety of the patient: (placepatient in a side lying position, securevascular access)-Assesses for the duration, type of seizure-Turns off UF-Refers to attending physician using SBARmethodology

7. Hypoglycemia-Assesses patients complaints such as(blurring of vision, dizziness and coldclammy skin)



P a g e | 18

-If patient is awake, lets him eatcarbohydrates (15 grams)-If patient becomes unconscious, givesglucose infusion-Rechecks capillary blood glucose (CBG)fifteen (15) minutes-Refers using SBAR methodology

8. Nausea and vomiting-Assesses for the cause (hypotension, uremiaand disequilibrium syndrome)-Intervenes according to the cause-Refers using SBAR methodology

9. Clotting of the extracorporeal circuit-Checks for patients vital signs-Quantifies the amount of blood loss-Refers using SBAR methodology-Recommends to physician to order forComplete Blood Count before the nexttreatment

Determines appropriate action to address theidentified intra-dialysis complications

As evidenced by:● Results of direct observation by the assessor● Completed HD treatment flow sheet● Completed Nurse’s Progress Notes, Nursing


● Referral to the physician using SBAR ifcomplications are not resolved



P a g e | 19

Competency Level 4: Perform proper blood samplingNCRENL4HDA11Task 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 OutstandingCollects blood samples for Pre HD (blood extractionin patients access will be done before the start of thetreatment)As evidenced by:

● Pre HD Blood Checklist● Documentation in Nurses Notes

Collects blood samples for Intra HD (during thetreatment, can be done by decreasing the BFR to 100ml/min for 15 seconds then aspirate blood fromarterial site or arterial collecting port of thebloodline)

As evidenced by:● Intra HD Blood Checklist● Documentation in Nurses Notes

Collects blood samples for prescribed work-up:Post HD (after the treatment blood extraction can bedone in venous injection port before the reinfusionof blood will be done or get sample directly from theaccess)

As evidenced by:● Post HD Blood Checklist● Documentation in Nurses Notes






P a g e | 20

Competency Level 4: Terminate dialysis treatment according to protocolNCRENL4HDA12Task 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 OutstandingEnds the dialysis treatment

As evidenced by:● Completed procedure checklist (AVF and

CVC)● Completed HD flow sheet, Nurses Progress

notes● Results of direct observation by the assessor

Ends the dialysis treatment



notes● Results of direct observation by the assessor

Documents termination



notes● Results of direct observation by the

assessor






P a g e | 21

Competency Level 4: Prepare vascular access NCRENL4HDA13Task Description: Evaluates the candidate’s ability to monitor and assess outcomes of care, and formulate recommendations


Performs cannulation of Arteriovenous Fistula(AVF) and Arteriovenous Graft (AVG)

As evidenced by:● Completed competency assessment tool for

cannulating AVG and AVF. (see attachedprocedure checklist, 17 criteria)

Central Venous Catheters (CVC)● Completed competency assessment tool for

central venous catheters. (see attachedprocedure checklist, 21 criteria)







Competency Level 4: Determine patient response and adequacy of treatment NCRENL4HDA14Task Description: Evaluates the candidate’s ability to monitor and assess outcomes of care, and formulate recommendations




P a g e | 22

Documents patient responses and measures ofdialysis adequacyAs evidenced by:

● Accomplishing HD flow sheet that includesthe following but not limited to: notableevents, Kt/V or URR, access recirculation,substitution fluid achieved (for HDFtherapies) and net Ultrafiltration (UF)achieved

● Documentation of Pre and post weight andvital signs

● Referral of patients who experienced anyconditions/complications (after performingindependent nursing management) usingSBAR

● Documentation on Nurses Progress notes● Results of direct observation by the assessor

Able to accomplish 1-2 outof 5 evidences





P a g e | 23

Competency Level 4: Provide health education to patient and significant other NCRENL4HDB01Task 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 OutstandingExplains medical and nursing management for HDpatientsAs evidenced by:

● Mastery of subject matter● Ability to communicate (proper use of words,

eyes contact, gestures) with patient andsignificant others clearly

● Confidence and professionalism whileteaching

● Ability to use creative and effective teachingmethods

● Ability to answer questions or clarifies points






P a g e | 24

Competency Level 4: Use health teaching in addressing healthy lifestyle, risk reducing behaviors, developmental needs, activities ofdaily living and self-care CRENL4HDB02Task Description: Evaluates the candidate’s ability to provide patient-specific and additional information relevant to promotion ofhealth, prevention and continuing care

Criteria Satisfactory Very Satisfactory OutstandingIdentifies compliance to medical regimen (HDprescription, medicine, fluid management, diet) asbasis for focus of health teachings

As evidenced by:● Documentation of health teachings given on

HD prescription, medicine, fluidmanagement, diet

● Provision of reference materialsRefers to appropriate section for other patient careneeds e.g., dietician, physical therapistAs evidenced by:

● Documentation of health teachings given onHD prescription, medicine, fluidmanagement, diet

● Provision of reference materialsConducts health teaching on the topics identified(healthy lifestyle, risk reducing behaviors,developmental needs, activities of daily living andself-care)As evidenced by:

● Documentation of health teachings given onHD prescription, medicine, fluidmanagement, diet

● Provision of reference materials






P a g e | 25

Competency Level 4: Use appropriate information technology to facilitate communication like Nurse module, Hospital Information System(HIS) NCRENL4HDC01Task 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

Communicates effectively using appropriate HIS

As evidenced by:

● Completed HIS procedure checklist● Input of correct information

Identifies HIS-related problems

As evidenced by:

● Completed HIS procedure checklist● Use of appropriate module (e.g. Nursing

Module, Pharmacy Module, Central SupplyModule)

Performs basic troubleshooting (e.g., if downtime, useof manual form)

As evidenced by:● Completed HIS procedure checklist● Use of appropriate manual






P a g e | 26

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/conferences

As 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 activities

As 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 welfare

As evidenced by:● Copy of Minutes of the Meeting● Other means






P a g e | 27

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



P a g e | 28

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






P a g e | 29

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



P a g e | 30

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






P a g e | 31


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






P a g e | 32

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






P a g e | 33

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



P a g e | 34

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






P a g e | 35

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






P a g e | 36

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




P a g e | 37

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






P a g e | 38

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




Date post:	21-Feb-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times