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Hospice Skills Checklist | ||||||
| NAME | |||||||
| LAST 4 OF SSN | |||||||
| DATE | |||||||
| I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination. | |||||||
| 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 below to describe your experience/expertise in each area listed below. | |||||||
| Proficiency Scale: |
1 = No Experience 2 = Need Training 3 = Able to perform with supervision 4 = Able to perform independently |
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| Rating Stars (Click) | WORK SETTINGS | 1 | 2 | 3 | 4 | ||
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Home Hospice | ||||||
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Inpatient Hospice | ||||||
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Pediatric Hospice | ||||||
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Home Health/Hospice Setting | ||||||
| Rating Stars (Click) | ASSESSMENT | 1 | 2 | 3 | 4 | ||
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Intake Assessment | ||||||
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Assessment Interview | ||||||
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Physical Exam | ||||||
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Coping Status | ||||||
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Environmental Status | ||||||
| Rating Stars (Click) | PLAN OF CARE | 1 | 2 | 3 | 4 | ||
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Set Goals with Pt/Family | ||||||
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Collaborate with Other Team Members | ||||||
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Ensure Continuity of Care | ||||||
| Rating Stars (Click) | SYMPTOM MANAGEMENT | 1 | 2 | 3 | 4 | ||
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Urgent Assessment of Symptoms | ||||||
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Reduce Symptoms to Level Acceptable to Pt. | ||||||
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Report Symptoms/Management to Provider | ||||||
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Treat Underlying Cause | ||||||
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Severity Scale | ||||||
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Management of Nausea | ||||||
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Management of Constipation | ||||||
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Management of Fatigue | ||||||
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Anorexia/Cachexia | ||||||
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Restlessness | ||||||
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Educate Family on Symptom Management | ||||||
| Rating Stars (Click) | PAIN MANAGEMENT | 1 | 2 | 3 | 4 | ||
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Identify Source of Pain | ||||||
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Pain Severity | ||||||
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PAINAD Scale for Non Verbal Patient | ||||||
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Reduce Pain to Level Acceptable to Patient | ||||||
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WHO 3 Step Ladder | ||||||
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Non-Pharmacologic Management of Pain | ||||||
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Pharmacologic Management of Pain | ||||||
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Effects of Pharmacologic Treatment | ||||||
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Nociceptive/Neuropathic/Mixed Pain | ||||||
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Management of Nociceptive Pain | ||||||
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Management of Neuropathic Pain | ||||||
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Educate Family on Pain Management | ||||||
| Rating Stars (Click) | WOUND CARE | 1 | 2 | 3 | 4 | ||
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Positioning Techniques | ||||||
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Bed/Support Surface Selection | ||||||
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Pressure Ulcer Staging/Management | ||||||
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Response to Treatment | ||||||
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Evaluate Factors that Impede Healing | ||||||
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Educate Family on Positioning/Shearing | ||||||
| Rating Stars (Click) | PEDIATRICS | 1 | 2 | 3 | 4 | ||
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Developmentally Appropriate Assessment | ||||||
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Parental/Sibling Support | ||||||
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Pediatric Support Team Collaboration | ||||||
| Rating Stars (Click) | MEDICATION ADMIN | 1 | 2 | 3 | 4 | ||
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Equianalgesic Conversion Formula | ||||||
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Titration of opioids | ||||||
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IV Pump Management | ||||||
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Evaluate Effectiveness of Medications | ||||||
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Family Management of Medications | ||||||
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Disposal of Medications | ||||||
| Rating Stars (Click) | AFTER DEATH | 1 | 2 | 3 | 4 | ||
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Facility Family/Cultural Rituals/Rites | ||||||
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Patient Care after Death | ||||||
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Coordinate Mortuary Services | ||||||
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Bereavement Services | ||||||
| Rating Stars (Click) | COMPLIANCE | 1 | 2 | 3 | 4 | ||
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Scope and Frequency of Services | ||||||
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Medicare/State Regulations for Hospice | ||||||
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Document Progression of Decline | ||||||
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DME Authorization & Documentation of Need/Order | ||||||
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OASIS-C | ||||||
| Rating Stars (Click) | PROFESSIONAL KNOWLEDGE AND SKILLS | 1 | 2 | 3 | 4 | ||
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Identify Source of Suffering | ||||||
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Palliative Care Philosophy | ||||||
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Patient/Family Directs Goals of Care | ||||||
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Maximize Quality of Life | ||||||
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Cultural Diversity | ||||||
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Supervision of Ancillary Staff | ||||||
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National Patient Safety Goals/Core Measures | ||||||
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Fall Risk Assessment/Prevention | ||||||
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Infection Prevention | ||||||
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Isolation Precautions | ||||||
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Interpretation and Communication of Lab Values | ||||||
| Rating Stars (Click) | EMR | 1 | 2 | 3 | 4 | ||
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Epic | ||||||
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Cerner | ||||||
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Eclipsys | ||||||
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Allscripts | ||||||
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McKesson | ||||||
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Meditech | ||||||
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Other Computerized System | ||||||
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Computerized Physician Order Entry | ||||||
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Bar Coding for Medication Administration | ||||||
| EMR Conversion | |||||||
| CERTIFICATIONS | Expiry Date : | ||||||
| BLS | |||||||
| CHPN | |||||||
| ACHPN | |||||||
| CHPPN | |||||||
| Other: Specify | |||||||
| Other: Specify | |||||||