Registered Nurse (RN) Performance Evaluation

Date of Hire :

Date of Evaluation :

Probationary Evaluation

Annual Evaluation

Responsibility, Skill, or Procedure

Yes

No

Completes the following documents thoroughly and accurately :

Intake Form

Yes

Consent for Treatment.

Yes

Statement of Financial Disclosure

Yes

Admission Checklist

Yes

Insurance Card Verification/Medicare Secondary Payer

Yes

Reviews and discusses with client/family the following information :

Patient’s Bill of Rights

Yes

Statement of Non-Discrimination

Yes

Advance Directive/Living Will

Yes

HIPAA/Privacy Practices Notice

Yes

OASIS Consent

Yes

How to contact the agency; how to lodge a complaint, home health hotline

Yes

In-Home Safety Checklist

Yes

Completes the following assessments thoroughly and accurately :

Cardiopulmonary System

Yes

Respiratory System

Yes

Gastrointestional System

Yes

Genitourinary System

Yes

Head, Eyes, Ears, Nose & Throat

Yes

Neurological System

Yes

Psychological

Yes

Endocrine

Yes

Integumentary System

Yes

Comfort/Pain Level

Yes

ADLs/Environment/Social

Yes

Medication Profile

Yes

Nutritional Profile

Yes

Completes the following medical records thoroughly and accurately :

Nursing Assessment

Yes

Intermittent Nursing Visit

Yes

Progress Notes (as needed)

Yes

Discharge/Transfer Record

Yes

Medication Record

Yes

Clearly communicates with physician regarding :

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

Yes

Observations & Clinical Changes

Yes

Obtaining verbal orders

Yes

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

Durable Medical Equipment/supplies

Yes

Pharmaceutical supplies (Medications)

Yes

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

Yes

Communicates appropriately with the other members of healthcare team including :

Home Health Aide

Yes

Physical Therapist

Yes

Occupational Therapist

Yes

Medical Social Worker

Yes

Speech-Language Pathologist

Yes

Other: (identify):

Yes

Supervision of Home Health Aide :

Develops Home Health Aide Plan of Care

Yes

Instructs Home Health Aide in Plan of Care

Yes

Performs Home Health Aide Supervisory Visits every 14 days

Yes

Supervision of LPN :

Performs LPN Supervisory Visits every 30 days

Yes

Other areas/skills :

Performs skilled care as required

Yes

Administers medications as required

Yes

Performs teaching to client/family/home health aide

Yes

Maintains client confidentiality

Yes

Conducts self in a professional manner

Yes

Reports to supervisor as needed and appropriate

Yes

Maintains OSHA Guidelines for Bloodborne Pathogens

Yes

Participates in interdisciplinary conferences and other committees as requested

Yes

Date :

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