Responsibility, Skill, or Procedure
Yes
No
Completes the following documents thoroughly and accurately :

Progress notes reflecting skilled interventions following plan of care

Intermittent Nursing Visit documentation

Travel/Time Log completed and turned in per agency policy

Updates plan of care

Other :

Reviews and discusses with client/family the following information :

Patient safety issues and means to maintain a safe home environment

Review and discussion of medications and teaching of side effects

Teaches safe use of equipment

Treatments and care procedures are taught and explained

Other :

Completes the following assessments thoroughly and accurately :

Cardiopulmonary System

Respiratory System

Gastrointestinal System

Genitourinary System

Head, Eyes, Ears, Nose & Throat

Neurological System

Psychological

Endocrine

Integumentary System

Comfort/Pain Level

ADLs/Environment/Social

Medication Profile

Nutritional Profile

Other :

Clearly communicates with physician regarding :

Plan of Care development and changes to plan of care (HCFA 485)

Observations and clinical changes

Obtaining verbal orders

Changes in plan of care or significant changes in patient’s condition

Identifies and assists client/family in accessing community resources including :

Durable Medical Equipment/supplies

Pharmaceutical supplies (Medications)

Access to other resources through referral to other team members or community programs relative to client’s needs

Communicates appropriately with the other members of healthcare team including :

Registered Nurse

Physical Therapist

Occupational Therapist

Medical Social Worker

Speech-Language Pathologist

Home Health Aide

Other: (identify) :

Other areas/skills :

Performs teaching to client/family/home health aide

Administers medications as required

Performs teaching to patient/family

Maintains Client Confidentiality

Conducts self in a professional manner

Reports to Supervisor as needed and appropriate

Maintains OSHA Guidelines for Bloodborne Pathogens

Participates in interdisciplinary conferences as requested

Patient Care Coordination/Productivity :

Coordinates patient care with RN for an average caseload of 20-25 patients

Understands all aspects of patient care oversight from scheduling to physician calls

Maintains a standard productivity of 25-35 visits per week as a full-time LPN

Understands when to call RN for support and assistance regarding care

All patient paperwork including visit notes and orders are accurate, complete and written at time of service provision or immediately thereafter and turned into agency within 24 hours of service/visit completion.

My signature below does not imply my agreement with the content of this evaluation, but that the above evaluation has been reviewed with me.