Initial Skill/Equipment Performance Checklist

INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST (CLINICAL/NON-CLINICAL) ST. ELIZABETH MEDICAL CENTER

Associate Department Cath Lab Recovery

Job Title Cath Lab Recovery Evaluation Period

Instructions: Record each activity to be evaluated. Assessment of “Meets Expectations” indicates the individual meets the performance expectations for the skill/competency. A rating of “Does Not Meet” requires documentation of an action plan for correction, a repeat evaluation, and a competency demonstration within 30-90 days. Note any relevant comments in the adjacent column.

SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS

VERBALIZES/DEMONSTRATES THE NURSING PROCESS: A. Assessment/Interventions of assigned patients. 1. Care based on: M DNM N/A a. Age specified needs

b. Physical assessment M DNM N/A

c. Psychosocial assessment M DNM N/A

d. Spiritual assessment M DNM N/A

e. Changes in patient’s condition M DNM N/A

B. Develops plan of care. 1. Develops/incorporates patient out- M DNM N/A comes in documentation

C. Evaluation. 1. Addresses patient outcomes M DNM N/A

2. Referrals M DNM N/A

COMMUNICATES AND DIRECTS PERTINENT INFORMATION TO THE HEALTH CARE TEAM: A. Interacts with patients, visitors, physicians M DNM N/A co-workers, & nurse managers

B. Reports changes in patient’s condition M DNM N/A to charge nurse, supervisor and MD

C. Reports to next shift M DNM N/A

*Skills specific to licensure are to be reviewed by someone of like discipline.

1 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS

DEMONSTRATES PROFESSIONAL RESPONSIBILITY UTILIZING VISION & VALUES BY OBSERVING: A. Dress code M DNM N/A

B. Staffing guidelines M DNM N/A

C. Patient rights M DNM N/A

D. Associate handbook M DNM N/A

E. Confidentiality M DNM N/A

F. Advance directives M DNM N/A

G. Participation in C.Q.I. studies (example: M DNM N/A crash cart/defibrillator check, pyxis discrepancy check, refrigerator/freezer temp check)

H. Delegation M DNM N/A

I. Charge nurse role M DNM N/A

J. Chain of command M DNM N/A

K. Nursing delivery system. 1. Accepts accountability for the care of the M DNM N/A patients

2. Responsible for plan of care and M DNM N/A decision making

3. Sets mutual goals between nurse and M DNM N/A patient/family

4. Responsible in patient/family teaching and M DNM N/A discharge planning

LOCATES AND UTILIZES: A. Compliance 360/MSDS in computer M DNM N/A

B. Procedure manual M DNM N/A

C. Nursing policy manual M DNM N/A

D. Nursing process tools manual M DNM N/A

E. Safety & infection control manual M DNM N/A

F. Time clock M DNM N/A

2 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER

G. Lab manual M DNM N/A

H. Code blue manual M DNM N/A

I. Approved abbreviation manual M DNM N/A

J. Staff meting minutes M DNM N/A

K. Memo book M DNM N/A

L. Patient/family education catalogue M DNM N/A

M. Additional reference materials M DNM N/A

KNOWS PROPER USAGE AND TROUBLE SHOOTING OF EQUIPMENT: A. Phone system M DNM N/A

B. Medstar M DNM N/A

C. Intercom/nurse call/pocket pagers/phones M DNM N/A

D. 02 flow meter M DNM N/A

E. Pulse oximeter. M DNM N/A 1. Continuous-Mellcor N-395

F. Emergency 02 tank M DNM N/A

G. I.V. pump. M DNM N/A Model: Baxter Flo Gard 6201

H. Syringe pump. M DNM N/A Model: Mini-infuser 150XL

I. Suctions. 1. Wall M DNM N/A

J. Chest tubes. 1. Heimlich valve M DNM N/A

K. Doppler. M DNM N/A Model: Imex Pocket-Dop II Model: Data scope L. Automatic B/P Cuff. M DNM N/A Model: Propaq 104/EL Model: Witt Biomedical Model: GE Pruka

M. Pyxis M DNM N/A

N. Jackson Pratt M DNM N/A

O. Bed operation/stretcher. 1. Electric: M DNM N/A a. Bed degrees

b. Code blue position M DNM N/A

c. Stretchers M DNM N/A

COMPLETES DOCUMENTATION PER PROCEDURE: A. Occurrence reports. 1. Patient/visitor M DNM N/A

2. Medication/solution M DNM N/A

3. Employee M DNM N/A

4. Clinical engineering service request M DNM N/A

B. Valuables form M DNM N/A

C. Patient data base M DNM N/A

D. Fall risk assessment M DNM N/A

E. Patient flow sheet M DNM N/A

F. Restraint flow sheet M DNM N/A

G. Transfer forms (extended care, acute care, M DNM N/A ambulance medicare/medicaid)

H. Medicare exempt units transfers (discharge/ M DNM N/A Readmit)

I. Patient discharge summary instructions M DNM N/A

J. Cardiopulmonary arrest record M DNM N/A

K. Crash cart/defibrillator checklist M DNM N/A

L. Consent forms. M DNM N/A 1. Surgical

2. Cardiovascular procedure M DNM N/A

3. Autopsy and release of body authorization M DNM N/A

4. Anatomical gift by next of kin or other M DNM N/A authorized person

5. Blood consent M DNM N/A

6. Blood refusal M DNM N/A

M. M.A.R. M DNM N/A

N. Pain management flow sheet M DNM N/A

O. Precautions during transportation M DNM N/A

P. Blood administration record M DNM N/A

Q. Pre-op checklist M DNM N/A

R. Temporary lab reports/lab reports M DNM N/A

S. Routine orders M DNM N/A

T. Advance directives M DNM N/A

U. Labeling of specimens M DNM N/A

V. Documentation in progress notes M DNM N/A

W. DNR treatment plan M DNM N/A

X. Pyxis Discrepancy report M DNM N/A

Y. Witt system M DNM N/A

OBSERVES SAFETY: A. Side rail M DNM N/A

B. Fall prevention M DNM N/A

C. Seizure precautions M DNM N/A

D. Elopement precautions M DNM N/A

E. Suicide precautions M DNM N/A

F. Disaster procedures M DNM N/A

G. Smoking regulations M DNM N/A

H. Utilizes safety representative M DNM N/A

I. Handling & disposal of sharps M DNM N/A

OBSERVES INFECTION CONTROL: A. BSI M DNM N/A

B. Contact precautions M DNM N/A

C. Mask precautions M DNM N/A

D. AFB precautions M DNM N/A

RETURNS DEMONSTRATION OF: A. Sterile dressing change M DNM N/A

B. Medication administration M DNM N/A

1. IM M DNM N/A

2. Subcutaneous M DNM N/A

3. IV M DNM N/A

4. PO M DNM N/A

C. Pre-Procedure care M DNM N/A

D. Post-procedure care M DNM N/A

E. Specimen collection. 1. Routine urine M DNM N/A

2. CCMS urine M DNM N/A

3. Straight cath M DNM N/A

4. From a foley M DNM N/A

5. 24 hour urine M DNM N/A

6. Stool for blood M DNM N/A

F. Wound care protocol M DNM N/A

1. Skin integrity NPT M DNM N/A

G. 02 therapy. M DNM N/A 1. Nasal

2. Ambu bag/bag valve mask (BVM) M DNM N/A

3. Venti mask M DNM N/A

4. NRB mask M DNM N/A

5. Adult intertech resuscitator M DNM N/A

H. Restraint/application of/removal. 1. Alternatives M DNM N/A

2. Chest M DNM N/A

3. Limb M DNM N/A

4. Handmitts M DNM N/A

I. Catheter. M DNM N/A 1. Care

2. Insertion of male M DNM N/A

3. Insertion of coude catheter M DNM N/A

4. External male catheter M DNM N/A

5. Insertion of female. M DNM N/A a. Straight or indwelling

6. Removal of foley M DNM N/A

7. Leg bag M DNM N/A

8. Emptying foley drainage bag M DNM N/A

J. NG tube single double lumen. M DNM N/A 1. Insertion

2. Removal M DNM N/A

3. Irrigation M DNM N/A

4. Suction M DNM N/A

K. Mobility of patient. M DNM N/A 1. Bed to chair

2. Bed to stretcher M DNM N/A

3. R.O.M.l M DNM N/A

4. Ambulate M DNM N/A

5. Positioning M DNM N/A

6. Smooth mover M DNM N/A

L. Suction. 1. Oral M DNM N/A

2. Nasal M DNM N/A

3. Tracheostomy M DNM N/A

M. Central line. 1. Assisting in the insertion of M DNM N/A

2. Use/changing 2 way valve M DNM N/A

3. Drawing blood (vacutainer/blood transfer M DNM N/A device)

4. Dressing change M DNM N/A

5. Flushing protocols M DNM N/A

6. I.V.P.B. M DNM N/A

7. PICC lines M DNM N/A

8. Groshong M DNM N/A

9. I.V. push M DNM N/A

N. Blood. M DNM N/A 1. Administer blood/blood products

2 Pall filter M DNM N/A

3. Reactions M DNM N/A

O. Peripheral line. 1. Insertion of angiocath M DNM N/A

2. Dressing IV site M DNM N/A

3. Administration of fluids M DNM N/A

4. Tubing change M DNM N/A

5. IV push medications M DNM N/A

6. Administering IVPB M DNM N/A

7. Add/missing IVs M DNM N/A

8. Needle less principles M DNM N/A

9. Monitoring M DNM N/A

10. Saline lock M DNM N/A

11. Use of extension M DNM N/A

12. IV conversion to saline lock M DNM N/A

13. D/C IV M DNM N/A

P. Chest tubes. 1. Assisting with the insertion of M DNM N/A

2. Set up of system M DNM N/A

3. Connecting to suction M DNM N/A

Initials Signature Title Initials Signature Title

Date: Associate Signature:

Date: Manager Signature:

To be completed yearly at the time of performance appraisal.

“I am still currently up-to-date on the above mentioned procedures.”

Associate Sign Date Mgr Sign