Clinical Skills Evaluation: Phlebotomy (7 Skills)
Evaluator Name
First Name
Last Name
Candidate Name
First Name
Last Name
Testing Site Name
Date
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Day
Year
Date
Time
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Hour
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Minutes
AM
PM
AM/PM Option
DERMAL PUNCTURE (P-CS1) (P-CS2) (P-CS3)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: Glucose Test Competency Check (P-CS1)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: CS1 Glucose Test Competency Check
Perform (YES)
Perform (NO)
1. Assemble equipment and supplies
2. Verify physician’s orders
3. Wash hands/don PPE (follow standard precautions)
4. Greet the patient
5. Identify yourself (name and designation)
6. Identify patient (full name & date of birth)
7. Explain the procedure
8. Ask patient about adherence to dietary restrictions
9. Remove reagent strip from container
10. Replace lid on container
11. Correctly perform capillary puncture (dermal) using a lancet
12. Wipe away first drop of blood
13. Place drop of blood on reagent strip/insert reagent strip into analyzer
14. Read results & apply bandage to the punctured finger
15. Clean and disinfect device
16. Dispose of sharps and contaminated supplies
17. Wash hands ( follow standard precautions )
18. Record results in patient chart
Select the steps that the candidate is:
Select the steps that the candidate is:
Evaluator Comments (Reference: CS1 Glucose Test Competency Check)
AECA: Capillary Finger Stick Competency Check (P-CS2)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: P-CS2 Capillary Finger Stick Competency Check
Perform (YES)
Perform (NO)
1. Assemble and prepare equipment and supplies
2. Wash hands (follow standard precautions)
3. Greet the patient
4. Identify yourself (name & designation)
5. Identify patient (full name & date of birth)
6. Verify the lab tests ordered against the requisition
7. Explain procedure to the patient
8. Select the puncture site (warm the site if necessary)
9. Wear Gloves (follow standard precautions)
10. Position patient (palmar side of hand facing up)
11. Clean site with alcohol
12. Air dry site
13. Position & hold the patient’s finger
14. Make the puncture in the appropriate area
15. Dispose of lancet
16. Gently squeeze patient’s finger
17. Wipe first drop of blood
18. Collect sample in appropriate micro‐collection container, without air bubble
19. Seal the micro‐collection container
20. Apply direct pressure / Ask the patient to apply direct pressure with gauze piece orcotton ball
21. Dispose of any contaminated materials
22. Inspect & bandage puncture site
23. Label specimens (by placing the capillary inside a tube & labeling that tube)
24. Thank the patient
25. Remove gloves
26. Wash hands (follow standard precautions)
27. Transport specimen to lab
28. Record in the phlebotomy log
Select the steps that the candidate is:
Select the steps that the candidate is:
Evaluator Comments (Reference: P-CS2 Capillary Finger Stick Competency Check)
AECA: Bleeding Time Test Competency Check (P-CS3)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: P-CS3 Bleeding Time Test Competency Check
Perform (YES)
Perform (NO)
1.Assemble equipment and supplies
2.Verify physician’s orders
3.Wash hands/don PPE (follow standard precautions)
4.Greet the patient
5.Identify yourself (name & designation)
6.Identify patient (full name & date of birth)
7.Explain procedure to the patient
8.Position patient comfortably
9.Determine adherence to medication restrictions (aspirin or any other)
10.Select incision site (_______________________________)
11.Clean site
12.Apply blood pressure cuff/inflate to 40 mm Hg, wait for 30 -60 seconds
13.Position the device parallel to the antecubital crease on the volar surfaceof the forearm. Perform incision at the site & wipe away first drop of blood
14.Blot blood at 30-seconds intervals until bleeding stops (keep recording)
15.Remove blood pressure cuff/clean arm
16.Apply steri-strip or butterfly bandage
17.Instruct patient in wound care & to keep the bandage in place for 24 hrs tominimize scarring
18.Dispose of sharps and contaminated material
19.Wash hands (follow standard precautions)
20.Record results in patient chart
Select the steps that the candidate is:
Select the steps that the candidate is:
Evaluator Comments (Reference: P-CS3 Bleeding Time Test Competency Check)
VENIPUNCTURE PUNCTURE (P-CS4) (P-CS5)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: Butterfly Infusion Set Competency Check (P-CS4)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: P-CS4 Butterfly Infusion Set Competency Check
Perform (YES)
Perform (NO)
1.Assemble and prepare equipment and supplies
2.Wash hands/don PPE (follow standard precautions)
3.Greet the patient
4.Identify yourself (name & designation)
5.Identify patient (full name & date of birth)
6.Verify the lab tests ordered against the requisition
7.Explain the procedure
8.Position patient comfortably
9.Apply tourniquet appropriately
10.Choose the puncture site and palpate the vein
11.Remove tourniquet
12.Clean site with alcohol
13.Air-dry site
14.Uncoil tubing/inspect needle (use appropriate gauge needle) /attach syringeof tube holder
15.Reapply tourniquet (if necessary)
16.Pull patient’s skin taut (to anchor the vein)
17.Holding the wings, insert the needle into the vein at appropriate angle
18.Fill syringe/evacuated tube in correct order of draw
19.Remove tourniquet within 60 seconds, even if in the middle of a draw
20.Untie tourniquet before withdrawing the needle
21.Activate safety device
22.Apply direct pressure / Ask the patient to apply pressure
23.Dispose of needle/syringe/tube holder in biohazard container
24.Transfer blood to evacuated tubes in correct order of draw (if syringe is used)
25.Mix tubes (follow the correct number of inversions)
26.Label tubes(patient’s name,date of birth, date and time of draw & your initial)
27.Check on patient-hemostasis
28.Apply bandage
29.Give instructions & thank patient
30.Dispose of waste
31.Package specimen for transport
32.Remove gloves/wash hands
33.Document in log book
Select the steps that the candidate is:
Select the steps that the candidate is:
Evaluator Comments (Reference: P-CS4 Butterfly Infusion Set Competency Check)
Evaluator Signature
AECA: Evacuated Tube Venipuncture Competency Check (P-CS5)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: P-CS5 Evacuated Tube Venipuncture Competency Check
Perform (YES)
Perform (NO)
1.Assemble and prepare equipment and supplies
2.Wash hands/don PPE (follow standard precautions)
3.Greet the patient
4.Identify yourself (name & designation)
5.Identify patient (full name & date of birth)
6.Verify the lab tests ordered against the requisition
7.Explain the procedure to the patient
8.Position patient comfortably
9.Apply tourniquet at the appropriate location
10.Select site
11.Remove tourniquet
12.Clean site with alcohol
13.Air-dry site
14.Uncoil tubing/inspect needle (use appropriate gauge needle) /attachsyringe of tube holder
15.Reapply tourniquet (if necessary)
16.Pull patient’s skin taut to anchor vein
17.Insert needle at an appropriate angle
18.Fill evacuated tubes in correct order of draw
19.Remove tourniquet within 60 seconds, even if in the middle of the draw
20.Untie tourniquet before withdrawing the needle
21.Remove last tube from the adapter before removing the needle
22.Activate safety device
23.Apply direct pressure / Ask the patient to apply pressure
24.Dispose of needle/syringe/tube holder in biohazard container
25.Mix tubes (follow the correct number of inversions)
26.Label tubes (patient’s name, date of birth, date & time of draw, yourinitials)
27.Check on patient for hemostasis
28.Apply bandage
29.Give instructions & thank patient
30.Dispose of waste
31.Package specimen for transport
32.Remove gloves/wash hands
33.Document in log book
Select the steps that the candidate is:
Select the steps that the candidate is:
Evaluator Comments (Reference: P-CS5 Evacuated Tube Venipuncture Competency Check)
Evaluator Signature
URINALYSIS (P-CS6)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: Physical & Chemical Urinalysis Competency Check (P-CS6)
Important Note: The competency checklist has been designed only to provide general information. It is not intended to be comprehensive or provide any legal or medical advice.
AECA: P-CS6 Physical & Chemical Urinalysis Competency Check
Perform (YES)
Perform (NO)
1. Assemble equipment and supplies
2. Verify physician’s orders
3. Wash hands/PPE (follow standard precautions)
4. Greet the patient
5. Identify yourself (name & designation)
6. Identify patient (full name & date of birth)
7. Explain procedure to the patient
8. Instruct patient in specimen collection
9. Perform physical Urinalysis
10. Perform chemical Urinalysis
11. Dispose of contaminated supplies
12. Wash hands
13. Record results in patient chart
Select the steps that the candidate is:
Select the steps that the candidate is:
Evaluator Comments (Reference: P-CS6 Physical & Chemical Urinalysis Competency Check)
Evaluator Signature
Submit
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