Hospice CheckList

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

WORK SETTINGS Rating Stars (Click) 1 2 3 4  
Home Hospice 
Inpatient Hospice  
Pediatric Hospice 
Home Health/Hospice Setting 
ASSESSMENT Rating Stars (Click) 1 2 3 4  
Intake Assessment  
Assessment Interview  
Physical Exam 
Coping Status  
Environmental Status 
PLAN OF CARE Rating Stars (Click) 1 2 3 4  
Set Goals with Pt/Family  
Collaborate with Other Team Members  
Ensure Continuity of Care 
SYMPTOM MANAGEMENT Rating Stars (Click) 1 2 3 4  
Urgent Assessment of Symptoms  
Reduce Symptoms to Level Acceptable to Pt.  
Report Symptoms/Management to Provider  
Treat Underlying Cause  
Severity Scale  
Management of Nausea 
Management of Constipation  
Management of Fatigue  
Educate Family on Symptom Management 
PAIN MANAGEMENT Rating Stars (Click) 1 2 3 4  
Identify Source of Pain  
Pain Severity  
PAINAD Scale for Non Verbal Patient  
Reduce Pain to Level Acceptable to Patient 
WHO 3 Step Ladder  
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 
WOUND CARE Rating Stars (Click) 1 2 3 4  
Positioning Techniques  
Bed/Support Surface Selection  
Pressure Ulcer Staging/Management  
Response to Treatment  
Evaluate Factors that Impede Healing  
Educate Family on Positioning/Shearing 
PEDIATRICS Rating Stars (Click) 1 2 3 4  
Developmentally Appropriate Assessment  
Parental/Sibling Support  
Pediatric Support Team Collaboration 
MEDICATION ADMIN Rating Stars (Click) 1 2 3 4  
Equianalgesic Conversion Formula  
Titration of opioids  
IV Pump Management  
Evaluate Effectiveness of Medications  
Family Management of Medications  
Disposal of Medications 
AFTER DEATH Rating Stars (Click) 1 2 3 4  
Facility Family/Cultural Rituals/Rites  
Patient Care after Death  
Coordinate Mortuary Services  
Bereavement Services 
COMPLIANCE Rating Stars (Click) 1 2 3 4  
Scope and Frequency of Services  
Medicare/State Regulations for Hospice  
Document Progression of Decline  
DME Authorization & Documentation of Need/Order  
Identify Source of Suffering  
Palliative Care Philosophy  
Patient/Family Directs Goals of Care  
Maximize Quality of Life  
Cultural Diversity 
Supervision of Ancillary Staff 
National Patient Safety Goals/Core Measures  
Fall Risk Assessment/Prevention 
Infection Prevention  
Isolation Precautions  
Interpretation and Communication of Lab Values 
EMR Rating Stars (Click) 1 2 3 4  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration