CNA/Home Health Aide Skills Assessment Checklist

CNA/Home Health Aide Skills Assessment Checklist
First Name*
Last Name*
Date*

MonthDayYear
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
Unoccupied

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

MonthDayYear
Date
Should be Empty: