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.
WORK SETTINGS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Home Hospice |
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Inpatient Hospice |
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Pediatric Hospice |
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Home Health/Hospice Setting |
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ASSESSMENT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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PLAN OF CARE | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Set Goals with Pt/Family |
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Collaborate with Other Team Members |
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Ensure Continuity of Care |
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SYMPTOM MANAGEMENT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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PAIN MANAGEMENT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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WOUND CARE | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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PEDIATRICS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Developmentally Appropriate Assessment |
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Parental/Sibling Support |
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Pediatric Support Team Collaboration |
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MEDICATION ADMIN | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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AFTER DEATH | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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COMPLIANCE | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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PROFESSIONAL KNOWLEDGE AND SKILLS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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EMR | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
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 |
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