<p> COMPETENCY SKILLS CHECKLIST FORM GUIDELINES</p><p>Purpose: Use this form to outline one or more competencies. List only critical performance criteria to evaluate. </p><p>1. State the title[s] of the Competencies of Competency to be evaluated on the top of the form.</p><p>2. Print all demographic information as listed.</p><p>3. Place a check mark in the box indicating the age requirement(s) related to this competency based on the population served by the department.</p><p>4. State the selected Performance Criteria in behavioral terminology in the performance criteria column. [Example: The employee will be able to demonstrate…]</p><p>5. Enter the validation method(s) selecting from the alphabetical key on the form.</p><p>6. Enter “ME” for Meets Expectation or “NI” for Needs Improvement in the Evaluation Column.</p><p>7. Use the Comment Line to indicate follow-up plan if evaluation indicates need for improvement.</p><p>8. The validator signs and dates the form in the space provided.</p><p>Attach and send form to Human Resources with Performance Evaluation No Name Transplant Center</p><p>Job/Population specific competency Skills Checklist (clinical)</p><p>NAME/TITLE: ______DEPT/UNIT: ______</p><p>EMPLOYEE ID NUMBER: ______DIVISION: ______DATE: _____/_____/____</p><p>AGES: Neonate (< 30 days) Preschool (3-5 years) Adulthood (18- 69 years)   Infant (1 month to 1 year) School age (6-12 years) Later Adult (>70 years)  Toddler (1-3 years) Adolescent (13-18 years) </p><p>VALIDATION METHOD: A = Policy Review F = Case Study Exam K = N/A B = Direct Observation G = Documentation Review C = Video Review H = Self Learning Module (SLP) D = Verbalization I = Simulated Demonstration E = Written Exam J = Other (specify)</p><p>PERFORMANCE CRITERIA VALIDATION METHOD EVALUATION COMMENTS (May use more than one method) Assessment of renal transplant Meets Needs recipient Expectat Improve ions ment</p><p>B. Documents findings in nursing • Adheres to applicable assessment form within 12 hrs of federal, state, and local admission regulations for assessment criteria and frequency for healthcare consumers F. Prepares and revises nursing undergoing kidney care plan that reflects assessment replacement therapies findings (KRTs).  Recognizes the importance of the A. Follows No Name Transplant assessment parameters Center P&P on pt. identification identified by UNOS, and completion of surgical WHO (World Health checklist Organization), Healthy People 2020, or other organizations that influence nephrology nursing transplantation practice.</p><p>• Collects pertinent data, but not limited to demographics, social determinants of health, health disparities, and physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age- related, environmental, spiritual/transpersonal, and economic assessments in a systematic, on-going process with compassion and respect for the inherent dignity, worth, and unique attributes of every person. • Elicits the healthcare consumer, values, preferences, expressed and unexpressed needs, and knowledge of the health care situation.</p><p>• Engages the healthcare consumer and other interprofessional team members in holistic, culturally sensitive data collection. • Identifies barriers to effective communication based on psychosocial, literacy, financial, and cultural considerations. • Recognizes impact of one’s own personal attitudes, values, and beliefs on the assessment process. • Assesses the impact of family dynamics health and wellness. • Uses evidence-based assessment techniques, instruments, tools, available data, information, and knowledge relevant to the situation to identify patterns and variances. • Applies ethical, legal, and privacy guidelines and policies to the collection, maintenance, use, and dissemination of data and information. • Recognizes the healthcare consumer as the authority on their own health by honoring their care preferences. • Documents relevant data accurately and in a manner accessible to the interprofessional team. </p><p> Uses appropriate evidenced-based assessment techniques, instruments and tools </p><p>EMPLOYEE SIGNATURE: ______DATE: ______/______/______</p><p>VALIDATOR SIGNATURE: ______DATE: ______/______/______</p><p>Send to HR with Performance Appraisal</p>