<p> SAINT AGNES MEDICAL CENTER COMPETENCY VALIDATION SUMMARY: RETURNING Nursing School Instructors </p><p>Name: Institution:</p><p>This summary sheet indicates competencies completed by nursing school instructors bringing students to the Medical Center. Criteria for evaluation of each competency are kept on file in Development and Support Services.</p><p>Completed/Return Review Validation Method ed Signed by Nursing Ed Confidentiality & Network Access □ Read Online Information Agreement/HIPPA Information □ Submit Signed Access Agreement Form Recognizing Impaired Physician □ Read Module □ Submit Signed Acknowledgment Form Abuse Reporting □ Read Module □ Submit Signed Acknowledgment Form Date Completed Review Competencies Validation Method Signed by Educator Armbands □ Read Module DNAR/POLST □ Review Policy K-9: Do Not Attempt POLST Form Resuscitation □ Review POLST Form Standardized Procedures: □ Read Module . MRSA Screening □ Review Forms . Pneumonia & Influenza Vaccine Administration Restraints □ Read Module Overview NPSG □ Read NPSG FAQs Unusual Occurrences □ Read Module Limited English Proficiency: Interpreter and □ Read Module Communication Aides Test not applicable to instructors Safe Medication Administration □ Read Module Pharmaceutical Waste Test not applicable to instructors Pain Management and Tools □ Read Module Test not applicable to instructors Skills Validation Method Date/Validator NOVA Glucose Meter □ Validation by Qualified Trainer, AND □ Return Demonstration Powerchart Review □ Validation Insulin Pen and Needle Education □ Attend Skills Lab □ Return Demonstration IV Pump □ Attend Skills Lab □ Return Demonstration Date Completed Unit Review Preceptor Signature 4 Clinical Hours Review Completed with Preceptor My signature below indicates I have completed the exercises and reviewed the information and/or policies. I understand I am accountable for this information and responsible to incorporate this information in my practice at SAMC.</p><p>Signature: ______Date: ______</p><p>Print Name: ______</p>