Skills/Experience Checklist Registered Nurse This form is a self-assessment of your current skills and abilities upon initial application. This form is also used to document skill demonstration. EMPLOYEE PROFILE Employee Number Last Name First Name Middle Initial Direct Supervisor (Name) Date Form Initiated RN CPR Card expiration date – The instructions will guide you in completing this form. Previous Experience Instruction, Review, or Skill Demonstration (Sections Clinical Associate Must Complete) (Sections Supervisor or Preceptor Must Complete) Supervisor: Indicates whether or not a review of policies/procedures or Place an X in the appropriate column using the key instruction is required then document completion in the appropriate below columns. If C or D is selected, review the instruction and possibly the skills demonstration is required prior to assignment to applicable patients. KEY A = I am competent to supervise this skill Preceptor: Documents completion of skills demonstration or indicates NA as applicable. A date and initials in the Skill Demonstration column indicates B = I am competent to perform this skill without competency has been achieved. Do not date or initial until competency is supervision achieved. An additional column is provided for repeat demonstrations. C = I need to review this skill Complete the signature section at the end of this form. D = I need additional instruction on this skill All RNs must demonstrate competencies for items in bold text and marked E = I have not performed this with an asterisk (*) prior to the first assignment requiring those skills. Previous Experience Instruction, Review, or Demonstration For Repeat Required for all Review of Instruction Competency Review A B C D E Skills Demo / Skill Demo Complete Demonstration of Competency Needed RNs Date / Initials Date / Initials (Y/NA) Date / Initials * Bag Technique Needed (Y/N/NA) * Hand Hygiene *Aseptic Technique *Sterile Technique *Venous Blood Draws *Wound Vac Therapy Visit documentation Medication reconciliation Care coordination Development of physician orders OASIS completion Discharge/transfer/progress summaries Nursing plan of care development Case Management
Skills/Experience Checklist Registered Nurse This form is a self-assessment of your current skills and abilities upon initial application. This form is also used to document skill demonstration. EMPLOYEE PROFILE Last Name First Name Middle Initial Employee Number Direct Supervisor (Name) Date Form Initiated RN CPR Card – expiration date The instructions will guide you in completing this form. Previous Experience (Sections Clinical Associate Must Complete) Instruction, Review, or Skill Demonstration (Sections Supervisor or Preceptor Must Complete) Place an X in the appropriate column using the key below KEY A = I am competent to supervise this skill B = I am competent to perform this skill without supervision C = I need to review this skill D = I need additional instruction on this skill E = I have not performed this Supervisor: Indicates whether or not a review of policies/procedures or instruction is required then document completion in the appropriate columns. If C or D is selected, review the instruction and possibly the skills demonstration is required prior to assignment to applicable patients. Preceptor: Documents completion of skills demonstration or indicates NA as applicable. A date and initials in the Skill Demonstration column indicates competency has been achieved. Do not date or initial until competency is achieved. An additional column is provided for repeat demonstrations. Complete the signature section at the end of this form. All RNs must demonstrate competencies for items in bold text and marked with an asterisk (*) prior to the first assignment requiring those skills. Previous Experience Instruction, Review, or Demonstration Required for all RNs A B C D E Review of Needed (Y/N/NA) Review of Instruction Complete Date / Initials Skill Demo Needed (Y/NA) Competency Demonstration Date / Initials For Repeat Skills Demo / Competency Date / Initials * Bag Technique * Hand Hygiene *Aseptic Technique *Sterile Technique *Venous Blood Draws *Wound Vac Therapy Visit documentation Medication reconciliation Care coordination Development of physician orders OASIS completion Discharge/transfer/progress summaries Nursing plan of care development Case Management
Nursing+-+RN+Skills+Experience+Check+List+2016+.docx