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Name of Staff: _________________________________ Department/ Unit: ______________________________

Date: __________________________

Competency Checklist
COMPLETION GUIDELINES: 1. The learner will complete the Self-Assessment section prior to instruction in this module using the following legend: 1 = No experience and/or knowledge with this topic; 2 = Has some experience and/or knowledge of this topic; 3 = Able to function independently in this area. 2. The learner will complete the assigned learning options based upon recommendation from the educator/preceptor. 3. The educator/preceptor will initial and date the column for Demonstrates Competence when the learner has met the acceptable level of performance.

Responsibilities and Performance Criteria ASSESSMENT 1. Assesses patients psychosocial status and care needs (eg. sleep patterns, anxiety, anger, grief, support systems)

Self-Assessment

GENERAL PATIENT CARE Learning Options

Evaluation

Demonstrates Competence

Review hospital Preceptor confirms policies and procedures, the ability to: unit specific policies - Identify individual Partner with patient psychosocial preceptor/CNS to needs based on complete patient assessment data assessment - Identify resources to meet the patient and family psychosocial needs Review of hospital Preceptor confirms

Name and Signature of Unit Head Nurse

Name and Signature of Supervisor

Chief Nurse

Name of Staff: _________________________________ Department/ Unit: ______________________________

Date: __________________________

Assesses patients understanding and wishes related to advance directives and end-of-life care

policies and procedures, the ability to: unit specific policies - Identify issues related Partner with to end-of-life care and preceptor/CNS to advance directives for evaluate patient the individual patient understanding and based on assessment intent of documents data - Identify resources to help patient, family, and caregivers resolve issues. Partners with preceptor/CNS to perform complete systems assessment Preceptor confirms the ability to: - Perform system assessment with appropriate documentation on the medical record

Completes full system assessment

IMPLEMENTATION Review unit and hospital policies and procedures Partners with Preceptor confirms the ability to: - Complete the plan of care and document

Develops written plan of care based on identified patient needs and assessment data

Name and Signature of Unit Head Nurse

Name and Signature of Supervisor

Chief Nurse

Name of Staff: _________________________________ Department/ Unit: ______________________________

Date: __________________________

preceptor/CNS to develop individual patient plan of care Partners with preceptor/CNS to prioritize and provide patient care

appropriately in the medical record

Prioritizes nursing care for assigned critically ill patients based on assessment data and identified patient needs.

Preceptor confirms the ability to: - Identify and prioritize patient care needs on an ongoing basis based on assessment data

Implements standard of care for patients preand post-procedure (eg. surgery, interventional cardiology, endoscopy)

Individual clinical modules for specific procedure-related information Reviews unit and hospital policies and protocols Partners with preceptor/CNS to provide patient care

Preceptor confirms the ability to: - Explain the rationale for pre- and postprocedure patient management - Identify potential complications related to anesthesia, sedation, and/or the specific procedure

Name and Signature of Unit Head Nurse

Name and Signature of Supervisor

Chief Nurse