Republic of the Philippines DEPARTMENT OF HEALTH …ejobs.doh.gov.ph/ncp-update/pdf/ORN/Level 5 Self...

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 5 Certification in Operating Room Nursing

Name of Candidate: __________________________________________________________________

Hospital of current employment: ________________________________________________________

Introduction: A nurse Candidate who seeks to be certified as a specialist in Operating Room Nursing,Level 5, will have to accomplish this self-assessment form and prepare the needed evidence to show proofof competence. Upon accomplishment of the form, the candidate will discuss the data and the evidencewith his/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



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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 standards:Satisfactory, Very Satisfactory, Outstanding.

Competency Level 5 (Assessment): Synthesize assessment data in consideration of metabolic and other clinical conditions of the patientNCORNL5A01Task 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 OutstandingIntegrates assessment findings with patient’s clinicalcondition

As evidenced by:● Nurse’s Notes documentation● Recorded/recognized laboratory results● Documentation of patient’s condition and

referral for critical values

Analyzes contributing factors to metabolic and otherclinical conditions

As evidenced by:● Case analysis

Anticipates possible risks of surgery

As evidenced by:● Case analysis

Able to accomplish 1 out of3 criteria





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Competency Level 5: Develops various modalities for outcome-driven patient care in diverse settings NCORNL5A01Task Description: Evaluates the ability of the candidate to formulate nursing care plan parallel to and in support of medical care

Criteria Satisfactory Very Satisfactory OutstandingIdentifies minor and major changes in the outcomeof careAs evidenced by:

● Nurse’s Notes documentation● Recorded/recognized laboratory results● Documentation of patient’s condition and

referral for critical values or signs andsymptoms observed

Determines unique needs of the patientAs evidenced by:

● Nurse’s Notes documentation● Recorded/recognized laboratory results● Documentation of patient’s holistic needs

Revises care plan accordinglyAs evidenced by:

● Timely Nurse’s Notes documentation● Recorded/recognized laboratory results● Documentation of updated patient’s status

Discusses a theory that would support patientoutcome in a diverse settingAs evidenced by:

● Case analysis● Interview of candidate using a Checklist

Able to accomplish 1-2 outof 4 criteria





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Competency Level 5: Modify plan of care according to anticipated physiologic and behavioural responses NCORNL5A03Task 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 OutstandingImplements plan of care according to anticipatedphysiologic and behavioral responses

As evidenced by:● Nursing Care Plan● Nurses’ Progress Notes

Discusses physiologic and behavioral responsesbased on an individualized needs of the surgicalpatient

As evidenced by:● Interview of candidate● Nursing Care Plan● Nurses’ Progress Notes

Applies nursing theories based on individualizedpatient needs

As evidenced by:● Interview of candidate● Review of nursing care plan or equivalent● Nurses’ Progress Notes






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Competency Level 5: Validate effectiveness of plan of care through assessment of patient needs utilizing various strategies and methodologies.NCORNL5A04Task Description: Evaluates the candidate’s ability to monitor and assess outcomes of care, and formulate recommendations

Criteria Satisfactory Very Satisfactory OutstandingInterprets post operative audit tools (V/S, Pain scale,capillary refill, glasgow coma scale)

As evidenced by:● Nurses’ Progress Notes● Monitoring Flowsheet● Nursing Care Plan● Clearance assessment● Patient feedback form

Proposes a tool to validate effectiveness plan of care

As evidenced by:● Evaluation tool sample● Monitoring Flowsheet● Nursing Care Plan

Modifies policies and protocols based patient needs

As evidenced by:● Evaluation tool sample● Patient feedback form● Documentation of changes in policy and

protocol● Case analysis






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Competency Level 5: Design educational programs that would promote patient's self-responsibility in perioperative care NCORNL5B01Task 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 OutstandingDesigns perioperative health education

As evidenced by:● Copy of educational program● Documentation in Nurses Notes● Direct observation

Updates existing perioperative health educationprograms

As evidenced by:● Copy of educational program● Documentation in Nurses Notes● Direct observation

Incorporates program to plan of care

As evidenced by:● Documentation in Nurses Notes● Instructional teaching plan






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Competency Level 5: Facilitate engaging communication on the plan of care promoting a partnered relationship in the plan of careNCORNL5C01Task Description: Evaluates the ability of the candidate to provide the patient and his/her family all information relevant to the patient’s careand elicit collaboration from them to achieve positive outcomes

Criteria Satisfactory Very Satisfactory OutstandingFacilitates engaging communication on the plan ofcare to patient and family.

As evidenced by:● Observation of candidate● Nurse’s Notes● Documentation of information provided

Utilizes all type of communication (oral, written,information technology)

As evidenced by:● Observation of candidate● Nurse’s Notes● Other source

Anticipates needs of patient and significant othersthrough verbal and non-verbal cues

As evidenced by:● Documentation of interview of patient and

significant others● Observation of candidate● Nurse’s Notes






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Competency Level 5: Integrate multi-disciplinary management and linkages to client care NCGENL5D01Task 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 OutstandingOrganizes multidisciplinary meeting/s based on theneeds of the patientAs evidenced by:

● Notice of Meeting with Agenda● Copy of Minutes of the Meeting with

Attendance● Any other forms of documentation

Acts as the nursing service representative duringmultidisciplinary discussionsAs evidenced by:

● Report from attendance● Accomplished Nursing Care Plan● Copy of Minutes of the Meeting● Any other forms of documentation

Suggests contingency plan/s related to delivery ofpatient care during multidisciplinary discussion andactivitiesAs evidenced by:

● Accomplished Nursing Care Plan● Copy of Minutes of the Meeting● Any other tools for documentation






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Competency Level 5: Participate in the review of institution's existing policies related to ethical issue and its implementation NCGENL5E01Task Description: Evaluates the candidate’s knowledge of and ability to abide by ethical rules of conduct in dealing with patient

Criteria Satisfactory Very Satisfactory OutstandingParticipates in meetings concerning discussion ofinstitution’s existing policies on ethical issuesAs evidenced by:

● Copy of Minutes of the Meeting● Documentation of the discussions made● Revision/Review forms for the existing

institution’s policies● Other means of documentation

Assures proper dissemination and implementation ofany amended ethical policies and guidelinesAs evidenced by:

● Notice for Action and Implementation bythe Executive Committee or any similardocument

● Documentation of execution andmonitoring of new implementedguidelines

● Copy of Performance Reports● Other means of documentation

Complies with institutional guidelines on properrevisions and amendments

As evidenced by:● Documentation of the revisions and

reviews done● Minutes of the Meeting● Other means of documentation






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Competency Level 5: Recommend strategies to maximize cost effectiveness of resources NCGENL5F01Task 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 OutstandingProjects medical supplies and equipment that wereproperly evaluated to be procured/par levelsidentified

As evidenced by:● Specification forms of needed medical

supplies and equipment● Utilization reports● Product evaluation reports● Patient property logbooks● Other related documentation

Monitors preventive maintenance and calibration ofmedical equipment

As evidenced by:● Accomplished preventive maintenance

and calibration forms● Schedule list of equipment requiring

preventive maintenance and calibration● Monitoring logbook for preventive

maintenance/calibration or similar● Other related documentation

Analyzes critical level of medical supplies, drugsand medicines






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As evidenced by:● Analysis report on critical level of

medical supplies, drugs, and medicines● Inquiry on knowledge on preventive

maintenance of medical equipment● Accomplished replenishment slips● Other related documentation

Competency Level 5: Perform regular review and updating of policies to continuously improve the record management NCGENL5G01Task 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 OutstandingParticipates in the formulation of recordkeepingpolicies and determination of archiving period

As evidenced by:● Records of Attendance to Committee

Meeting or similar● Copy of Minutes of the Meeting● Recommendation letters for revision of

forms or Document Request Form● Accomplished Performance Feedback

Forms● Other related documentation

Monitors the implementation of regular chart andrecord checking






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As evidenced by:● Monitoring reports for charts review or

similar reports● Accomplished Performance Feedback


Evaluates regularly the existing forms and recordsutilized for patient care documentation

As evidenced by:● Any report or record indicating a regular

evaluation of current patient care formsused

● Recommendation letters for revision orimprovement of existing forms orDocument Request Form

● Accomplished Performance FeedbackForms

● Other related documentation

Competency Level 5: Ensure absolute compliance in the guidelines and activities of the following: NCGENL5H01● 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 OutstandingAs evidenced by:

● Copy of Minutes of the Meeting ofAble to accomplish 1 out of

3 criteriaAble to accomplish 2-3 out

of 4 criteriaAble to accomplish 4 out of

4 criteria



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Nursing Quality Improvement andAssurance

● Quality Improvement Reports and Plan orsimilar reports

● Monitoring Reports of Non-conformities(if applicable)

● Other related documentation

Implements continuous quality improvement basedon research studiesAs evidenced by:

● Copy of CQI study● Tailored quality improvement program

plans based on reviewed studies● Actual implementation of quality

improvement programs● Monitoring reports related to the said

program/s● Accomplished Performance Feedback


Conducts quality improvement studiesAs evidenced by:

● Quality Improvement Study Proposals● Monitoring Reports related to the

significance of the Quality Improvementstudies to be performed

● Quality Improvement Study ProgressReports

● Completed CQI study● Other related documentation



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Competency Level 5: Develop policies based on identified issues and concerns to ensure quality and safe patient care and managementNCGENL5I01Task 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 OutstandingParticipates in policy review committee meetings orany similar institutional bodies, representing nurses’role in safe and quality patient care

As evidenced by:● Attendance reports of meetings● Copy of Minutes of the Meeting● Other related documentation

Recommends revision or review of policies relatingto quality nursing care

As evidenced by:● Recommendation letters for policy

revision/review● Attendance reports of meetings● Nurses’ Reflection Notes/ Nurses’ Diary● Accomplished Performance Feedback


Monitors the applicability, reliability and flexibility ofprotocols, guidelines, processes and policies relating tonurses’ role in patient care






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As evidenced by:● Monitoring reports for

policies/processes/protocols● Attendance reports of regular meetings● Nurses’ Reflection Notes/ Nurses’ Diary● Accomplished Performance Feedback


Competency Level 5: Serve as a mentor, adviser or principal investigator to enhance or improve nursing specialty practiceNCGENL5J01Task 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 OutstandingActs as mentor to other nurses in performingresearch studies

As evidenced by:● Performance Feedback Forms as research

mentor● Feedback documentation from peers● Other related documentation (e.g.

Progress and Monitoring Record of theResearch Proposal)

Advises nurse researchers while conducting theirgeneral and specialty nursing studies






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As evidenced by:● Performance Feedback Forms as research

adviser● Actual documented studies conducted by

advisees● Feedback documentation from peers● Other related documentation (e.g.


Spearheads nurse research groups in conductingnursing studies relevant to current practice

As evidenced by:● Performance Feedback Forms as

principal researcher and supervisor● Actual documented study/ies performed

by research group● Feedback documentation from peers● Other related documentation (e.g.




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Competency Level 5: Mentor others in leading effective time management in patient care NCGENL5K01Task 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 OutstandingComputes the staffing needs based on census, acuityof care, and staff skill set

As evidenced by:● Actual staffing computation sheet or

similar● Actual case scenario presentation and

inquiry of judgment● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation and similar

forms used in the institute

Prioritizes patient without assistance including usingcorrect priority setting framework

As evidenced by:● Actual case scenario presentation and

inquiry of judgment● Nurses’ Reflection Notes/Nurses’ Diary● Accomplished Performance Feedback

Forms● Other related documentation and similar


Delegates specific instructions to the nursingpersonnel to do appropriate tasks in a prioritizedorder including reporting back the results of eachtask delegated






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As evidenced by:● Actual case scenario presentation and

inquiry of judgment● Endorsement logbooks● Unit Management Reports or similar● Accomplished Performance Feedback

Forms● Feedback from peers and personnel● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation and similar


Identifies strategies to resolve conflictsAs evidenced by:

● Actual inquiry of judgment in a samplecase scenario

● Nurses’ Reflection Notes/Nurses’ Diary● Feedback from peers and personnel● Other related documentation and similar


Provides feedback on work performance based onset guidelines by the institutionAs evidenced by:

● Accomplished Personnel EvaluationForms or similar

● Consultation logs with personnel● Endorsement logbooks● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation and similarforms used in the institute



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Competency Level 5: Design lectures and seminars related to nursing specialty NCGENL5L01Task Description: Evaluate the candidate’s ability to demonstrate engagement in continuing education and self-development

Criteria Satisfactory Very Satisfactory OutstandingDevelops specialty lectures with the followingcriteria: relevant, appropriate, attainable and clearlydefined objectivesAs evidenced by:

● Lecture/course outlines● Certificates of Recognition/Attendance as

specialty lecturer● Lecture evaluation reports● Other related documentation

Facilitates at least two lectures/seminars/programsrelated to nursing specialty

As evidenced by:● Certificates of Recognition as facilitator● Program layout of specialty lectures● Program evaluation reports● Other related documentation

Conduct meetings to address professional/personaldevelopment needs of specialty nurses

As evidenced by:● Attendance of Meetings● Minutes of the Meeting● Accomplished Performance Evaluation

Reports● Other related documentation






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Competency Level 5: Act as a role model to professionalism and ethical behavior NCGENL5M01Task Description: Evaluate the candidate’s ability to demonstrate critical characteristics and behaviors that a specialist nurse should exhibit asa role model of expertise, excellent performance, and professionalism

Criteria Satisfactory Very Satisfactory OutstandingSeeks opportunities to build and improverelationships with coworkers, supervisors, and thepublic

As evidenced by:● Nurses’ Reflection Notes● Patients’ Satisfaction Survey Results● Accomplished Performance Feedback

Forms● Feedback from peers and superiors● Other related documentation

Takes the initiative to offer help to others based onhis or her assessment of the situation

As evidenced by:● Actual case scenario and inquiry ofjudgment● Nurses’ Reflection Notes/Nurses’ Diary● Feedback from peers and superiors● Other related documentation

Resolves conflicts professionally without theintervention of a higher management level






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As evidenced by:● Actual case scenario and inquiry of

judgment● Nurses’ Reflection Notes/Nurses’ Diary● Feedback from peers and superiors● Other related documentation

Receives positive feedback from coworkers

As evidenced by:● Commendation letters from peers and

superiors● Nurses’ Reflection Notes/Nurses’ Diary● Other related documentation

Republic of the Philippines DEPARTMENT OF HEALTH …ejobs.doh.gov.ph/ncp-update/pdf/ORN/Level 5 Self...

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