Please Check Appropriate Response
Satisfactory Can Safely Perform without Supervision
Unsatisfactory Additional Practice & Supervision Required
Instruction/ Training Date & Supervising RN Initials
Competency Achieved Date & Supervising RN Initials

Handwashing Technique

Applying Infection Control Theory to :

- Use of gloves

- Use & care of supplies

- Equipment, cleaning & disinfecting

- Disposal of medically related material

- Personal protective equipment

Bed Bath (complete)*

Bed Bath (complete)*

Shower Bath*

Tub Bath with Bench*

Back Rub*

Skin Care*

Recognizing and reporting changes in skin condition, including pressure ulcers and identify pressure points

Basic Care to Pressure Sores: *

- Position to relieve pressure areas*

- Wash with soap/water*

- Air dry skin/ulcer*

Bed Positioning*

- Side laying*

- Prone (back laying) *

- Use of draw sheet*

Mouth Care*

- Brush teeth*

- Brush dentures*

Mouth Care for Bedbound Patient*

Hair Care: *

- Comb/brush*

- Shampoo in sink*

- Shampoo in tub*

Shaving: *

- With electric shaver only*

Nail Care: *

- Clean, file fingernails*

- Soak, file toenails*

Assist with Clothing: *

- Bedfast patient*

- Wheelchair patient*

Bedmaking :

- Unoccupied

- Occupied

Use of Bed Pan: *

- Regular/fracture*

Use of Urinal*

Use and Care of Portable Commode*

Routine Catheter Care: *

- Foley catheter*

- Condom catheter*

Cleaning Perineum at Catheter Insertion Point*

Care/Changing of Leg Bag and/or Overnight Drainage Bag*

Perineal Care*

Vital Signs: *

- Weight*

- Oral temperature*

- Rectal temperature*

- Axillary temperature*

- Pulse*

- Respirations*

Use of Body Mechanics*

Range of Motion Exercise*

“Stand By” Ambulation*

Assisting with Canes*

Assisting with Walkers*

Assisting with Crutches*

Transfers: *

- Use & care of Hoyer Lift*

- Bed to wheelchair/BSC/Chair*

- Wheelchair to bed*

- Wheelchair to tub or shower bench*

Care of Patient’s Environment :

- Light housekeeping of pt’s area

- Laundry of patient items

- Cleaning patients bathtub/shower/sink

First Aid

Oxygen Safety :

- Assist with oxygen nasal prongs

Charting/Observation Skills*

Measuring Intake/Output

Basic Communication Skills*

- Active listening*

- Non-verbal communication*

- Interdisciplinary team communication*

- Verbally report clinical information to patients, representatives, caregivers and agency staff/supervisors*

- Ability to read and write

- Maintain open communication with patient/representative*

Recognize signs of hypoglycemia (low blood sugar)

Recognize signs of hyperglycemia (high blood sugar)

Sitz Bath

Assist with Colostomy care*

Apply TED hose/Jobst stockings

Nutritional Skills :

- Basic nutrition/simple meal preparation

- Offering fluids

- Preparation of foods for low sodium diet

- Preparation of food for diabetic diet

- Feeding patients with chewing/ swallowing problems

Assist with medications: Provide fluids :

- Bring meds in organizer or container

- Remind patient to take meds

- Apply non-prescription topical cream to intact skin

Other Specific Skills: