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Speech Therapy
Evaluation/Diagnosis/Prevention of speech impairment
Swallow evaluation and management
Speech fluency/ articulation
Cognitive communication
Medical Social Worker
Providing adequate resources for clients in the community
Short/long term planning of care
Adequate clients follow up
Home Health Aide
Medication reminders
Personal Care; Bed bath, using lift.
Vital signs monitoring & Report to Clinical Nurse
Certain housekeeping
Safety Supervision during Seizure
Symptom monitor and report to Clinical Nurse
Mobility support
Physical Occupational Therapy
Restore Function
Improve Mobility & Strength
Aid inside/outside ambulation
Range of motion, Positioning & Transfers
Control disabilities
Balancing & Gait
Promote ADL functions
Create an exercise plan
Promote Overall fitness
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Clinical Manager Job Description Form
Home Health Aide Competency & Job Description & Skill Validation
LPN Competency Job Description Form
MSW Competency Job Description Form
Occupational Therapist Assistant Job Description Form
Occupational Therapist Job Description Form
Physical Therapist Assistant Job Description Form
Physical Therapist Job Description Form
RN Job Description & Performance Evaluation & Competency Form
Speech Therapist Job Description Form
Resources
Employement
SanData
EVV
Home
About
Services
Skilled Medical Services
Prescription Refill and Management
Open Wound Dressing
Ostomy Care
Catheter Care
G-Tube Feeding
Vital Signs Monitoring And Report To PCP Doctor
Safety Supervision
Symptom Monitoring
Mobility Support
Speech Therapy
Evaluation/Diagnosis/Prevention of speech impairment
Swallow evaluation and management
Speech fluency/ articulation
Cognitive communication
Medical Social Worker
Providing adequate resources for clients in the community
Short/long term planning of care
Adequate clients follow up
Home Health Aide
Medication reminders
Personal Care; Bed bath, using lift.
Vital signs monitoring & Report to Clinical Nurse
Certain housekeeping
Safety Supervision during Seizure
Symptom monitor and report to Clinical Nurse
Mobility support
Physical Occupational Therapy
Restore Function
Improve Mobility & Strength
Aid inside/outside ambulation
Range of motion, Positioning & Transfers
Control disabilities
Balancing & Gait
Promote ADL functions
Create an exercise plan
Promote Overall fitness
Forms
Administrator Competency & Job Description Form
Clinical Manager Job Description Form
Home Health Aide Competency & Job Description & Skill Validation
LPN Competency Job Description Form
MSW Competency Job Description Form
Occupational Therapist Assistant Job Description Form
Occupational Therapist Job Description Form
Physical Therapist Assistant Job Description Form
Physical Therapist Job Description Form
RN Job Description & Performance Evaluation & Competency Form
Speech Therapist Job Description Form
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>
Registered Nurse Initial Competency
Registered Nurse Initial Competency
Scroll
Name
(Required)
Date of Hire
(Required)
MM slash DD slash YYYY
Date Completed
(Required)
MM slash DD slash YYYY
Demonstrates ability to obtain and document appropriate age specific history/assessment for patients and provide skilled nursing procedures in the following categories:
1) Self-Assessment
Proficien
Need Review
No Experience
1.Admission to agency
a. OASIS/Non-OASIS assessment form
b. Develops care plan based on assessment
c. Knowledge of nursing process
d. Health history/physical exam
e. Development of problem list and care planning
f. Conducts complete initial evaluation
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
2) Self-Assessment
Proficien
Need Review
No Experience
2. Transfer of patient
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
3) Self-Assessment
Proficien
Need Review
No Experience
3. Care coordination/discharge planning
a. Care planning
b. Care coordination
c. Case management
d. Adheres to POC
e. Documents and reports key information to physician, RN Case Manager, supervisor, care team
f. Coordinates community resources
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
4) Self-Assessment
Proficien
Need Review
No Experience
4. Documentation
a. CMS/state guidelines for documentation
b. Corrections to the clinical record
c. Accident/incident reports
d. Clinical notes, flow charts
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
5) Self-Assessment
Proficien
Need Review
No Experience
5. Other
a. Supervision of ancillary personnel
b. Supply requisition and management
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
Demonstrates ability to obtain and document appropriate age specific history/assessment for patients and provide skilled nursing procedures in the following categories:
1) Self-Assessment
Proficien
Need Review
No Experience
1. Pulmonary System
a. Pulmonary Assessment
b. Tracheostomy care
c. Oxygen administration
d. Pharyngeal suction
e. Use of oral/nasal inhalers
f. Oximeter
g. CPAP/BiPAP
h. Oxygen mask, nasal cannula, concentrator, portable oxygen
i. SVN/Nebulizer treatment
j. Home ventilator management
k. Foreign body airway obstruction
l. Breathing exercises/incentive spirometry
m. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
2) Self-Assessment
Proficien
Need Review
No Experience
2.Cardiovascular System
a. Cardiovascular assessment
b. Pulses (apical, radical, femoral, pedal)
c. Edema assessment and management
d. Supine and orthostatic blood pressure
e. CPR
f. Energy conservation techniques
g. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
3) Self-Assessment
Proficien
Need Review
No Experience
3.Neurologic System
a. Neurologic assessment
b. Aphasia care
c. Mental status exam
d. Seizure precautions
e. Spinal cord injuries care
f. Head injury care
g. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
4) Self-Assessment
Proficien
Need Review
No Experience
4.Gastrointestinal System
a. Gastrointestinal assessment
b. NG tube insertion/care
c. Jejunostomy tube care
d. Gastrostomy tube care
e. Enteral feedings
f. Suction machine(s)
g. Ostomy care
h. Dysphagia precautions
i. Impaction removal
j. Enema
k. Bowel training
l. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
5) Self-Assessment
Proficien
Need Review
No Experience
5.Genitourinary System
a. GU assessment
b. Urinary catheter insertion and care (male and female)
c. Irrigation of catheters
d. Obtaining specimens
e. Removal of urinary catheter
f. Care of supra-pubic catheter
g. Care of urostomy
h. Bladder training
i. Nephrostomy tubes
j. Knowledge of types of catheters and indications for use (straight, indwelling, condom)
k. Ileostomy care
l. Incontinence care
m. GU post op care
n. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
6) Self-Assessment
Proficien
Need Review
No Experience
6. Integumentary/Wounds/Dressings
a. Assessment of skin/wound
b. Measurement of wounds
c. Wound irrigation
d. Wet to dry dressing(s)
e. Wound Care:- Aseptic Technique
e. Wound Care:- Sterile Technique
e. Wound Care:- Wound Vac / PICO
f. Decubitus care:- Assessment and staging
f. Decubitus care:- Prevention
f. Decubitus care:- Various treatments (hydrocolloid, calcium alginate, transparent films)
f. Decubitus care- Documentation/pictures
g. Ace wrap, cast care, compresses
h. Hemovac drain
i. Suture/staple removal
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
7) Self-Assessment
Proficien
Need Review
No Experience
7.Musculoskeletal System
a. Assessment
b. Range of motion (ROM)
c. TED hose
d. Care of joint replacement patients
e. Cast assessment and care
f. Devices:- Walker
f. Devices:- Wheelchair
f. Devices:- Transfer board
f. Devices:- Hoyer lift
g. Transfers
h. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
8) Self-Assessment
Proficien
Need Review
No Experience
8. Pain assessment and management
a. Conducts pain evaluation including location, onset, intensity, duration, alleviating factors
b. Utilizes a pain rating scale to collect data
c. Knowledgeable about types of pain (neuropathic, visceral, bone, smooth muscle, psychologic)
d. Knowledgeable about drug therapies indication and dosing
- NSAIDS
- Steroids
- Benzodiazepines
- Tricyclic antidepressants
- Anticonvulsants
- Narcotics
- Other
e. Non-pharmacologic methods:
- Relaxation (guided imagery, meditation, massage)
- Psychologic (biofeedback, therapy)
- Neurologic (TENS)
- Ice/heat
f. Patient/family teaching
- Medication use, side effects
- Addiction vs. tolerance
- Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
9) Self-Assessment
Proficien
Need Review
No Experience
9. Metabolic
a. Assessment
b. Diabetic assessment and teaching
- Insulin types and teaching
- Use, care and teaching of glucose monitoring system
- Diet, exercise and sick day teaching
- Signs and symptoms of Hypo-Hyperglycemic reactions
- Foot and skin care
c. Hyper/hypothyroid assessment/teaching
d. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
10) Self-Assessment
Proficien
Need Review
No Experience
10.Behavioral Assessment
a. Psychosocial Status
b. Depression
c. Suicide precautions
d. Psychotropic drugs
e. Care of the demented patient
f. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
11) Self-Assessment
Proficien
Need Review
No Experience
11. Miscellaneous Skills
a. Vital signs
b. Intake and output
c. Caring for immuno-compromised patients
d. Eye/ear irrigation
e. Collection, labeling and delivering laboratory specimens (blood, urine, sputum, wound, stool)
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
1) Self-Assessment
Proficien
Need Review
No Experience
1.Medication Administration Techniques
a. Assessment
b. Diabetic assessment and teaching- Insulin types and teaching
b. Diabetic assessment and teaching- Use, care and teaching of glucose monitoring system
b. Diabetic assessment and teaching- Diet, exercise and sick day teaching
b. Diabetic assessment and teaching-- Signs and symptoms of Hypo-Hyperglycemic reactions
b. Diabetic assessment and teaching-- Foot and skin care
c. Hyper/Hypothyroid assessment/teaching
d. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
10) Self-Assessment
Proficien
Need Review
No Experience
10. Behavioral Assessment
a. Psychosocial Status
b. Depression
c. Suicide precautions
d. Psychotropic drugs
e. Care of the demented patient
f. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
11) Self-Assessment
Proficien
Need Review
No Experience
11. Miscellaneous Skills
a. Vital signs
b. Intake and output
c. Caring for immuno-compromised patients
d. Eye/ear irrigation
e. Collection, labeling and delivering laboratory specimens (blood, urine, sputum, wound, stool)
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
Medication Administration: Demonstrates ability to administer, monitor and document medications for patients.
1) Self-Assessment
Proficien
Need Review
No Experience
1.Medication Administration Techniques
a. Oral
b. Intramuscular
c. Intravenous-bolus/push
d. Subcutaneous
e. Suppositories
f. Ear, eye, nose drops
g. Anticoagulant therapy
h. Insulin administration, site rotation
i. Assessment for side effects, adverse reactions, therapeutic response
j. Assessment for side effects, adverse reactions, therapeutic response
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
2) Self-Assessment
Proficien
Need Review
No Experience
2.Intravenous Therapy
a. Technique and care of:- Venipuncture
a. Technique and care of- Butterfly
a. Technique and care of- Over the needle catheter
a. Technique and care of- Regulation of IV flow rate, use of infusion pumps
b. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
3) Self-Assessment
Proficien
Need Review
No Experience
3.Central Venous Access Devices
a. Drawing blood from
b. Site care
c. Flushing
d. Cap change
e. Needleless system
f. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
Infection Control
1) Self-Assessment
Proficien
Need Review
No Experience
1. Hand washing technique
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
2) Self-Assessment
Proficien
Need Review
No Experience
2. Aseptic technique
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
3) Self-Assessment
Proficien
Need Review
No Experience
3. Proper bag technique
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
4) Self-Assessment
Proficien
Need Review
No Experience
4. Safe needle technique
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
5) Self-Assessment
Proficien
Need Review
No Experience
5. Personal protective equipment
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
6) Self-Assessment
Proficien
Need Review
No Experience
6. Exposure control plan
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
7) Self-Assessment
Proficien
Need Review
No Experience
7. TB exposure control plan
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
8) Self-Assessment
Proficien
Need Review
No Experience
8. Reporting of infections for patient and personnel
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
9) Self-Assessment
Proficien
Need Review
No Experience
9. Standard precautions
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
Equipment
1) Self-Assessment
Proficien
Need Review
No Experience
1.Displays knowledge of the following:
a. Electric bed
b. Special beds
c. Alternating pressure mattress
d. Infusion pumps
e. Ambulatory infusion devices
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
2) Self-Assessment
Proficien
Need Review
No Experience
2.Home Glucose Monitoring:
a. Verbalizes purpose of test
b. Specimen collection
c. Instrument calibration
d. Quality control process
e. Test correctly performed and reported
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
3) Self-Assessment
Proficien
Need Review
No Experience
3. PT/INR Testing:
a. Verbalizes purpose of test
b. Specimen collection
c. Instrument calibration
d. Quality control process
e. Test correctly performed and reported
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
4) Self-Assessment
Proficien
Need Review
No Experience
4. other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
Safety
1) Self-Assessment
Proficien
Need Review
No Experience
1. Restraints, indications and policy
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
2) Self-Assessment
Proficien
Need Review
No Experience
2. Fire extinguishers
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
3) Self-Assessment
Proficien
Need Review
No Experience
3. Emergency preparedness
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
4) Self-Assessment
Proficien
Need Review
No Experience
4. Hazardous materials
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
5) Self-Assessment
Proficien
Need Review
No Experience
5. Assessment of patient safety risks and home safety
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
Patient Education
1) Self-Assessment
Proficien
Need Review
No Experience
1. Determine patient and family learning needs
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
2) Self-Assessment
Proficien
Need Review
No Experience
2. Sets measurable objectives
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
3) Self-Assessment
Proficien
Need Review
No Experience
3. Develops/implements teaching plan
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
4) Self-Assessment
Proficien
Need Review
No Experience
4. Evaluates effectiveness of teaching
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
5) Self-Assessment
Proficien
Need Review
No Experience
5. Revises teaching plan based on patient needs
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
6) Self-Assessment
Proficien
Need Review
No Experience
6. Documents response to teaching
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
7) Self-Assessment
Proficien
Need Review
No Experience
7. Provides instruction in the following:
a. Emergency care
b. Diet and nutrition
c. Medications - - Route, dosage, frequency, side effects, adverse reactions, safe storage, labeling, indications, drug/food interactions
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
8) Self-Assessment
Proficien
Need Review
No Experience
8. Provides instruction about advance directives and patient rights
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
8) Self-Assessment
Proficien
Need Review
No Experience
9. Other
Eval Method
Verbal Test
Written Test
Demo
Competent
Yes
No
Preceptor Initials
(Required)
Date
(Required)
MM slash DD slash YYYY
Search for:
Home
About
Services
Skilled Medical Services
Prescription Refill and Management
Open Wound Dressing
Ostomy Care
Catheter Care
G-Tube Feeding
Vital Signs Monitoring And Report To PCP Doctor
Safety Supervision
Symptom Monitoring
Mobility Support
Speech Therapy
Evaluation/Diagnosis/Prevention of speech impairment
Swallow evaluation and management
Speech fluency/ articulation
Cognitive communication
Medical Social Worker
Providing adequate resources for clients in the community
Short/long term planning of care
Adequate clients follow up
Home Health Aide
Medication reminders
Personal Care; Bed bath, using lift.
Vital signs monitoring & Report to Clinical Nurse
Certain housekeeping
Safety Supervision during Seizure
Symptom monitor and report to Clinical Nurse
Mobility support
Physical Occupational Therapy
Restore Function
Improve Mobility & Strength
Aid inside/outside ambulation
Range of motion, Positioning & Transfers
Control disabilities
Balancing & Gait
Promote ADL functions
Create an exercise plan
Promote Overall fitness
Forms
Administrator Competency & Job Description Form
Clinical Manager Job Description Form
Home Health Aide Competency & Job Description & Skill Validation
LPN Competency Job Description Form
MSW Competency Job Description Form
Occupational Therapist Assistant Job Description Form
Occupational Therapist Job Description Form
Physical Therapist Assistant Job Description Form
Physical Therapist Job Description Form
RN Job Description & Performance Evaluation & Competency Form
Speech Therapist Job Description Form
Resources
Employement
SanData
EVV
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