CNA/Home Health Aide Skills Assessment Checklist
First Name
*
Last Name
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Total years of CNA/HHA
*
Skills
Medication
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Medication Reminder
Reporting Med side Effects
Assist with Ambulation:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Walker
Cane
Manual Wheel Chair
Assist with Toileting:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Commode
Urinal
Bed Pan
Bathing:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Bed
Tub
Shower
Bedbound Care:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Bed making
Occupied
Uno
ccupied
Bowel Movements:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Constipation
Diarrhea
Cleaning
Cooking
Reporting Change of Condition
Foley Catheter Care:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Emptying Bag***
Diarrhea
Cleaning
Cooking
Reporting Change of Condition
Foley Catheter Care:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Emptying Bag***
Changing Leg Bag
Gloves:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Putting On*
Taking Off
Hand Washing
Oral Hygiene:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Dentures*
Brushing Teeth
Mouth Swabs
Ostomy:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Emptying Bag
Changing Bag
Oxygen/How to apply:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Emptying Bag
Safe issues- No smoking **
No open flames or candles, 02 signage visible at the main do
02 Tanks place in appropriate canister/ holder
Personal Care:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Positioning
ROM Exercises
Skin Care
Dressing a Patient
Perineal Care
Transfers:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Pt. weighing 100-150 lbs
Pt. weighing Over 200 lbs
Turning a patient
How to use a draw sheet
Vital Signs
Wheelchair Operation:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
How to lock chair
How to remove leg rest
Patient:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Working with children
Working with Dementia & Alzheimer Patient
Operate DME:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Manual Wheel Chair:
Power Wheel Chair
Hoyer Lift
Set-up tray Feeding:
*
Rows
No Experience
Need Instruction
Need Refreshing
Competent
Set-up tray
Partial Assistance
Total Feeding Assistance
Signature
*
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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