SKILLS CHECKLIST
Name
*
Date
*
-
Month
-
Day
Year
Date
SPECIALPROCEDURE
Please indicate level of skill
*
Rows
25%
50%
75%
100%
Resident admission procedure
Resident discharge procedure
Resident transfer procedure
Take and record: Temperature (Electronic/Temp Dots), Oral, Tympanic, Axillary, Pulse, Respiration, Blood pressure, Height, Weight
CPR (optional)
Heimlich
Post mortem care
Ostomy care
Respiratory care: (oxygen set-up; safety)
Other: Passing fresh water
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NUTRITION
Please indicate level of skill
*
Rows
25%
50%
75%
100%
Positioning (at table; in bed; during tube
feedings)
Assists residents who self-feed
(supervision/cueing)
Feeds dependent residents
Partial physical assist to eat
Serves supplements
Preparing & serving thickened liquids
Passes meal / supplement intake
Records meal / supplement intake
Records fluid intake / output
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PERSONAL CARE
Please indicate level of skill
*
Rows
25%
50%
75%
100%
Tub bath
Shower
Bed bath
Partial bath
Oral care
Denture care
Female pericare
Male pericare
Pericare with catheter
Nail care
Hair care
Shaving
Use of commode and bedpan
Dressing / undressing
Prevention/observation Pressure sore
Skin
care
Catheter care: Proper handling, emptying,
changing catheter bags
Obtain specimens: Urine, Stool, Sputum
Application of heat: Aqua pad, Compresses
Application of cold: Ice bag, Compresses
Application ted hose
Documentation in residents record
Assessment & care planning process
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INFECTION CONTROL
Please indicate level of skill
*
Rows
25%
50%
75%
100%
Bloody and body fluid precautions
Hand washing
Use of protective gown, gloves and mask
Disposal of contaminated supplies
Proper linen handling, storage and disposal
COMMUNICATIONS/RIGHTS
Please indicate level of skill
*
Rows
25%
50%
75%
100%
Respectful in interactions/communications
Knocks before entering
Ask permission/explains procedures in advance
Address resident by preferred name
Demonstrates techniques of responding to: Combative resident, Depressed resident, Anxious resident, Cognitively impaired
Ensures privacy during personal care
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ENVIRONMENT
Please indicate level of skill
*
Rows
25%
50%
75%
100%
Make an unoccupied bed
Make an occupied bed
Cleaning a resident unit
Marks & cares for personal possessions
Completes clothing & possessions list
Cleans resident care equipment (tub /
shower, basins, wheelchair, combs, brushes,
razor, etc.)
Care of glasses
Care of hearing aid
Care of prostheses
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SAFETY AND REHABILITATION
Please indicate level of skill
*
Rows
25%
50%
75%
100%
Uses correct body mechanics
Turn/position resident
Range of motion
Use of mechanical lifts
Ambulation techniques:
Use of gait belt
Use of mobility equipment
TRANSFERS
Please indicate level of skill
*
Rows
25%
50%
75%
100%
Bed to chair
Chair to bed
One person
Two person
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Miscellaneous:
Please indicate level of skill
*
Rows
25%
50%
75%
100%
ADL retraining
Bowel/bladder retraining
Use of restraints (e.g. Lap buddy, Geri
chair, wedge, etc.)
Use of side rails
Use of call lights
Submit
Should be Empty: