SKILLED NURSE /SKILLS CHECKLIST SELF-EVALUATION
Name
First Name
Last Name
Date
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Month
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Day
Year
Date
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Instructions: Using the scale below, please record the number next to the skill to evaluate your ability to perform the skill. This form must be completed before the first case assignment.
SCALE:1= Experienced, can perform without direct supervision 2= Some experience, but need review or supervision 3= No experience, needs training and supervision 4= Not applicable, LPN
OASIS ASSESSMENT (RN only)
1
2
3
4
1 is , 4 is
Supervision of LPNs or Aides (RN only)
1
2
3
4
1 is , 4 is
Nutritional assessment
1
2
3
4
1 is , 4 is
Wound assessment, care, management, and dressing changes
1
2
3
4
1 is , 4 is
Insertion, care, and maintenance of foley or suprapubic catheter
1
2
3
4
1 is , 4 is
Diabetes management, insulin injections
1
2
3
4
1 is , 4 is
Glucometer testing, care, calibration
1
2
3
4
1 is , 4 is
Pain management
1
2
3
4
1 is , 4 is
IM injections
1
2
3
4
1 is , 4 is
Sub-Q injections
1
2
3
4
1 is , 4 is
Venipuncture for lab draws
1
2
3
4
1 is , 4 is
Starting peripheral IVs
1
2
3
4
1 is , 4 is
PICC management, lab draws, dressing changes
1
2
3
4
1 is , 4 is
IV management, infusions, hydration
1
2
3
4
1 is , 4 is
Ostomy care
1
2
3
4
1 is , 4 is
Bowel and bladder training
1
2
3
4
1 is , 4 is
Patient teaching and training of diseases, treatments, IV, etc.
1
2
3
4
1 is , 4 is
Discharge planning
1
2
3
4
1 is , 4 is
Wound vac changes, care, wound assessments
1
2
3
4
1 is , 4 is
Submit
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