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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