Instructions: This checklist is
meant to serve as a general guideline for our client facilities as to the
level of your skills within your nursing specialty. Please use the scale
(PROFICIENCY)
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
(FREQUENCY)
1 = Never performed observed only
2 = Less than 6 times per year
3 = 1-2 times per month
4 = Daily or Weekly
PROFICIENCY / FREQUENCY
PROFICIENCY
FREQUENCY
Home Health/Hospice Setting
Collaborate with Other Team Members
Ensure Continuity of Care
Urgent Assessment of Symptoms
Reduce Symptoms to Level Acceptable to Pt.
Report Symptoms/Management to Provider
Management of Constipation
Educate Family on Symptom Management
PAINAD Scale for Non Verbal Patient
Reduce Pain to Level Acceptable to Patient
Non-Pharmacologic Management of Pain
Pharmacologic Management of Pain
Effects of Pharmacologic Treatment
Nociceptive/Neuropathic/Mixed Pain
Management of Nociceptive Pain
Management of Neuropathic Pain
Educate Family on Pain Management
Bed/Support Surface Selection
Pressure Ulcer Staging/Management
Evaluate Factors that Impede Healing
Educate Family on Positioning/Shearing
Developmentally Appropriate Assessment
Pediatric Support Team Collaboration
Equianalgesic Conversion Formula
Evaluate Effectiveness of Medications
Family Management of Medications
Facility Family/Cultural Rituals/Rites
Coordinate Mortuary Services
Scope and Frequency of Services
Medicare/State Regulations for Hospice
Document Progression of Decline
DME Authorization & Documentation of Need/Order
PROFESSIONAL_KNOWLEDGE_AND_SKILLS
Identify Source of Suffering
Palliative Care Philosophy
Patient/Family Directs Goals of Care
Supervision of Ancillary Staff
National Patient Safety Goals/Core Measures
Fall Risk Assessment/Prevention
Interpretation and Communication of Lab Values
Other Computerized System
Computerized Physician Order Entry
Bar Coding for Medication Administration