<p> INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST (CLINICAL/NON-CLINICAL) ST. ELIZABETH MEDICAL CENTER</p><p>Associate Department Cath Lab Recovery </p><p>Job Title Cath Lab Recovery Evaluation Period </p><p>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.</p><p>SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS</p><p>VERBALIZES/DEMONSTRATES THE NURSING PROCESS: A. Assessment/Interventions of assigned patients. 1. Care based on: M DNM N/A a. Age specified needs</p><p> b. Physical assessment M DNM N/A</p><p> c. Psychosocial assessment M DNM N/A</p><p> d. Spiritual assessment M DNM N/A</p><p> e. Changes in patient’s condition M DNM N/A</p><p>B. Develops plan of care. 1. Develops/incorporates patient out- M DNM N/A comes in documentation</p><p>C. Evaluation. 1. Addresses patient outcomes M DNM N/A</p><p>2. Referrals M DNM N/A</p><p>COMMUNICATES AND DIRECTS PERTINENT INFORMATION TO THE HEALTH CARE TEAM: A. Interacts with patients, visitors, physicians M DNM N/A co-workers, & nurse managers</p><p>B. Reports changes in patient’s condition M DNM N/A to charge nurse, supervisor and MD</p><p>C. Reports to next shift M DNM N/A</p><p>*Skills specific to licensure are to be reviewed by someone of like discipline.</p><p>1/06</p><p>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</p><p>DEMONSTRATES PROFESSIONAL RESPONSIBILITY UTILIZING VISION & VALUES BY OBSERVING: A. Dress code M DNM N/A</p><p>B. Staffing guidelines M DNM N/A</p><p>C. Patient rights M DNM N/A</p><p>D. Associate handbook M DNM N/A</p><p>E. Confidentiality M DNM N/A</p><p>F. Advance directives M DNM N/A</p><p>G. Participation in C.Q.I. studies (example: M DNM N/A crash cart/defibrillator check, pyxis discrepancy check, refrigerator/freezer temp check)</p><p>H. Delegation M DNM N/A</p><p>I. Charge nurse role M DNM N/A</p><p>J. Chain of command M DNM N/A</p><p>K. Nursing delivery system. 1. Accepts accountability for the care of the M DNM N/A patients</p><p>2. Responsible for plan of care and M DNM N/A decision making</p><p>3. Sets mutual goals between nurse and M DNM N/A patient/family</p><p>4. Responsible in patient/family teaching and M DNM N/A discharge planning</p><p>LOCATES AND UTILIZES: A. Compliance 360/MSDS in computer M DNM N/A</p><p>B. Procedure manual M DNM N/A</p><p>C. Nursing policy manual M DNM N/A</p><p>D. Nursing process tools manual M DNM N/A</p><p>E. Safety & infection control manual M DNM N/A</p><p>F. Time clock M DNM N/A</p><p>2 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER</p><p>SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS</p><p>G. Lab manual M DNM N/A</p><p>H. Code blue manual M DNM N/A</p><p>I. Approved abbreviation manual M DNM N/A</p><p>J. Staff meting minutes M DNM N/A</p><p>K. Memo book M DNM N/A</p><p>L. Patient/family education catalogue M DNM N/A</p><p>M. Additional reference materials M DNM N/A</p><p>KNOWS PROPER USAGE AND TROUBLE SHOOTING OF EQUIPMENT: A. Phone system M DNM N/A</p><p>B. Medstar M DNM N/A</p><p>C. Intercom/nurse call/pocket pagers/phones M DNM N/A</p><p>D. 02 flow meter M DNM N/A</p><p>E. Pulse oximeter. M DNM N/A 1. Continuous-Mellcor N-395</p><p>F. Emergency 02 tank M DNM N/A</p><p>G. I.V. pump. M DNM N/A Model: Baxter Flo Gard 6201</p><p>H. Syringe pump. M DNM N/A Model: Mini-infuser 150XL</p><p>I. Suctions. 1. Wall M DNM N/A</p><p>J. Chest tubes. 1. Heimlich valve M DNM N/A</p><p>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</p><p>M. Pyxis M DNM N/A</p><p>N. Jackson Pratt M DNM N/A</p><p>3 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER</p><p>SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS</p><p>O. Bed operation/stretcher. 1. Electric: M DNM N/A a. Bed degrees</p><p> b. Code blue position M DNM N/A</p><p> c. Stretchers M DNM N/A</p><p>COMPLETES DOCUMENTATION PER PROCEDURE: A. Occurrence reports. 1. Patient/visitor M DNM N/A</p><p>2. Medication/solution M DNM N/A</p><p>3. Employee M DNM N/A</p><p>4. Clinical engineering service request M DNM N/A</p><p>B. Valuables form M DNM N/A</p><p>C. Patient data base M DNM N/A</p><p>D. Fall risk assessment M DNM N/A</p><p>E. Patient flow sheet M DNM N/A</p><p>F. Restraint flow sheet M DNM N/A</p><p>G. Transfer forms (extended care, acute care, M DNM N/A ambulance medicare/medicaid)</p><p>H. Medicare exempt units transfers (discharge/ M DNM N/A Readmit)</p><p>I. Patient discharge summary instructions M DNM N/A</p><p>J. Cardiopulmonary arrest record M DNM N/A</p><p>K. Crash cart/defibrillator checklist M DNM N/A</p><p>L. Consent forms. M DNM N/A 1. Surgical</p><p>2. Cardiovascular procedure M DNM N/A</p><p>3. Autopsy and release of body authorization M DNM N/A</p><p>4. Anatomical gift by next of kin or other M DNM N/A authorized person</p><p>4 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER</p><p>SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS</p><p>5. Blood consent M DNM N/A</p><p>6. Blood refusal M DNM N/A</p><p>M. M.A.R. M DNM N/A</p><p>N. Pain management flow sheet M DNM N/A</p><p>O. Precautions during transportation M DNM N/A</p><p>P. Blood administration record M DNM N/A</p><p>Q. Pre-op checklist M DNM N/A</p><p>R. Temporary lab reports/lab reports M DNM N/A</p><p>S. Routine orders M DNM N/A</p><p>T. Advance directives M DNM N/A</p><p>U. Labeling of specimens M DNM N/A</p><p>V. Documentation in progress notes M DNM N/A</p><p>W. DNR treatment plan M DNM N/A</p><p>X. Pyxis Discrepancy report M DNM N/A</p><p>Y. Witt system M DNM N/A</p><p>OBSERVES SAFETY: A. Side rail M DNM N/A</p><p>B. Fall prevention M DNM N/A</p><p>C. Seizure precautions M DNM N/A</p><p>D. Elopement precautions M DNM N/A</p><p>E. Suicide precautions M DNM N/A</p><p>F. Disaster procedures M DNM N/A</p><p>G. Smoking regulations M DNM N/A</p><p>H. Utilizes safety representative M DNM N/A</p><p>I. Handling & disposal of sharps M DNM N/A</p><p>5 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER</p><p>SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS</p><p>OBSERVES INFECTION CONTROL: A. BSI M DNM N/A</p><p>B. Contact precautions M DNM N/A</p><p>C. Mask precautions M DNM N/A</p><p>D. AFB precautions M DNM N/A</p><p>RETURNS DEMONSTRATION OF: A. Sterile dressing change M DNM N/A</p><p>B. Medication administration M DNM N/A</p><p>1. IM M DNM N/A</p><p>2. Subcutaneous M DNM N/A</p><p>3. IV M DNM N/A</p><p>4. PO M DNM N/A</p><p>C. Pre-Procedure care M DNM N/A</p><p>D. Post-procedure care M DNM N/A</p><p>E. Specimen collection. 1. Routine urine M DNM N/A</p><p>2. CCMS urine M DNM N/A</p><p>3. Straight cath M DNM N/A</p><p>4. From a foley M DNM N/A</p><p>5. 24 hour urine M DNM N/A</p><p>6. Stool for blood M DNM N/A</p><p>F. Wound care protocol M DNM N/A</p><p>1. Skin integrity NPT M DNM N/A</p><p>G. 02 therapy. M DNM N/A 1. Nasal</p><p>2. Ambu bag/bag valve mask (BVM) M DNM N/A</p><p>3. Venti mask M DNM N/A</p><p>4. NRB mask M DNM N/A</p><p>6 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER</p><p>SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS</p><p>5. Adult intertech resuscitator M DNM N/A</p><p>H. Restraint/application of/removal. 1. Alternatives M DNM N/A</p><p>2. Chest M DNM N/A</p><p>3. Limb M DNM N/A</p><p>4. Handmitts M DNM N/A</p><p>I. Catheter. M DNM N/A 1. Care</p><p>2. Insertion of male M DNM N/A</p><p>3. Insertion of coude catheter M DNM N/A</p><p>4. External male catheter M DNM N/A</p><p>5. Insertion of female. M DNM N/A a. Straight or indwelling</p><p>6. Removal of foley M DNM N/A</p><p>7. Leg bag M DNM N/A</p><p>8. Emptying foley drainage bag M DNM N/A</p><p>J. NG tube single double lumen. M DNM N/A 1. Insertion</p><p>2. Removal M DNM N/A</p><p>3. Irrigation M DNM N/A</p><p>4. Suction M DNM N/A</p><p>K. Mobility of patient. M DNM N/A 1. Bed to chair</p><p>2. Bed to stretcher M DNM N/A</p><p>3. R.O.M.l M DNM N/A</p><p>4. Ambulate M DNM N/A</p><p>5. Positioning M DNM N/A</p><p>6. Smooth mover M DNM N/A</p><p>7 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER</p><p>SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS</p><p>L. Suction. 1. Oral M DNM N/A</p><p>2. Nasal M DNM N/A</p><p>3. Tracheostomy M DNM N/A</p><p>M. Central line. 1. Assisting in the insertion of M DNM N/A</p><p>2. Use/changing 2 way valve M DNM N/A</p><p>3. Drawing blood (vacutainer/blood transfer M DNM N/A device)</p><p>4. Dressing change M DNM N/A</p><p>5. Flushing protocols M DNM N/A</p><p>6. I.V.P.B. M DNM N/A</p><p>7. PICC lines M DNM N/A</p><p>8. Groshong M DNM N/A</p><p>9. I.V. push M DNM N/A</p><p>N. Blood. M DNM N/A 1. Administer blood/blood products</p><p>2 Pall filter M DNM N/A</p><p>3. Reactions M DNM N/A</p><p>O. Peripheral line. 1. Insertion of angiocath M DNM N/A</p><p>2. Dressing IV site M DNM N/A</p><p>3. Administration of fluids M DNM N/A</p><p>4. Tubing change M DNM N/A</p><p>5. IV push medications M DNM N/A</p><p>6. Administering IVPB M DNM N/A</p><p>7. Add/missing IVs M DNM N/A</p><p>8 INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST ST. ELIZABETH MEDICAL CENTER</p><p>SKILL/PROCEDURE/EQUIPMENT DATE M = MEETS COMMENTS/ACTION REVIEWED/ EXPECTATIONS PLAN REVIEWED BY DNM = DOES NOT MEET (Initials)* EXPECTATIONS</p><p>8. Needle less principles M DNM N/A</p><p>9. Monitoring M DNM N/A</p><p>10. Saline lock M DNM N/A</p><p>11. Use of extension M DNM N/A</p><p>12. IV conversion to saline lock M DNM N/A</p><p>13. D/C IV M DNM N/A</p><p>P. Chest tubes. 1. Assisting with the insertion of M DNM N/A</p><p>2. Set up of system M DNM N/A</p><p>3. Connecting to suction M DNM N/A</p><p>Initials Signature Title Initials Signature Title</p><p>Date: Associate Signature: </p><p>Date: Manager Signature: </p><p>To be completed yearly at the time of performance appraisal. </p><p>“I am still currently up-to-date on the above mentioned procedures.”</p><p>Associate Sign Date Mgr Sign </p><p>Associate Sign Date Mgr Sign </p><p>Associate Sign Date Mgr Sign </p><p>Associate Sign Date Mgr Sign </p><p>9</p>