This checklist was electronically signed on (Today’s date)
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
Home Hospice
Inpatient Hospice
Pediatric Hospice
Home Health/Hospice Setting
Intake Assessment
Assessment Interview
Physical Exam
Coping Status
Environmental Status
Set Goals with Pt/Family
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
Treat Underlying Cause
Severity Scale
Management of Nausea
Management of Constipation
Management of Fatigue
Anorexia/Cachexia
Restlessness
Educate Family on Symptom Management
Identify Source of Pain
Pain Severity
PAINAD Scale for Non Verbal Patient
Reduce Pain to Level Acceptable to Patient
WHO 3 Step Ladder
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
Positioning Techniques
Bed/Support Surface Selection
Pressure Ulcer Staging/Management
Response to Treatment
Evaluate Factors that Impede Healing
Educate Family on Positioning/Shearing
Developmentally Appropriate Assessment
Parental/Sibling Support
Pediatric Support Team Collaboration
Equianalgesic Conversion Formula
Titration of opioids
IV Pump Management
Evaluate Effectiveness of Medications
Family Management of Medications
Disposal of Medications
Facility Family/Cultural Rituals/Rites
Patient Care after Death
Coordinate Mortuary Services
Scope and Frequency of Services
Medicare/State Regulations for Hospice
Document Progression of Decline
DME Authorization & Documentation of Need/Order
OASIS-C
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
Epic
Cerner
Eclipsys
Allscripts
McKesson
Meditech
Other Computerized System
Computerized Physician Order Entry
Bar Coding for Medication Administration
EMR Conversion - yes
BLS
CHPN
ACHPN
CHPPN
Other: Specify
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