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Competency Checklist, Long Term Care


First Name: _______________                   Last Name: ________________                Date: ______________________

Age – Specific Practice
Please list your TOTAL years’ experience in caring for the following age groups:

A. Newborn (Up to 30 days)                  D. Preschooler (4-5 yrs.)                     G. Young Adults (18-39 yrs.)
B. Infant (30 days to 1 yr.)                E. School Age (5-12 yrs.)                     H. Middle Aged Adults (39-64 yrs.)
C. Toddler (1-3 yrs.)                       F. Adolescents (12-18 yrs.)                   I. Older Adults (64 yrs. And older)

Please indicate your experience with the above-listed age groups: (Check the appropriate boxes)

                                                                                            A    B    C    D    E    F     G    H   I
Able to adapt care to incorporate normal growth and development
Able to adapt method and terminology of patient instructions to their age,
comprehension and maturity level
Can ensure a safe environment reflecting specific needs of various age groups

Please indicate your level of experience in the following areas. Rank each skill using the following
numbers to indicate your level of proficiency:

1. Clinical Observation or didactic learning: No experience

2. Limited or infrequent experience

3. Experienced. May occasionally need resource assistance

4. Proficient: Can perform/teach without assistance

               GENERAL SKILLS                                 EXP.                        GENERAL SKILLS                        EXP.
New Admissions and Transfers:                                           HIPAA policies
                                                                        Preparing for and explaining routines to patient
Room preparation
                                                                        and /or family
Vital signs, height, weight                                             Post-mortem care
Inventory and disposition of belongings                                 Caring for Drains/Tubes (i.e. Hemovac, Penrose)
Room orientation/call light                                             Monitoring and Assessing I & O
Basic comfort measures                                                  Performing complex dressing changes
Pain management                                                         Alert charting
Interpretation of lab values                                            Charges
Reference materials                                                     Telephone system
Documentation                                                           Incident reports
Reports to shift staff                                                  Patient teaching and documentation of teaching
Alternate communication systems                                         Computerized documentation

                                         developed by Beth Nash, RN from
Task delegation                                               Multidisciplinary POC
Discharge of patient                                          Obtaining cultures: blood, sputum, urine

                   ASSESSMENTS                        EXP.                       ASSESSMENTS                   EXP.
Activating Code Terms                                         Respirations
Applying Oximeter                                             Scale Use: standing, chair, bed
BP, Including orthostatic                                     Temperature: Axillary
Bringing emergency equipment to room                          Temperature: Oral
Emergency defibrillation                                      Temperature: Rectal
DNR status                                                    Temperature: Tympanic
Pulse: Radial                                                 Use of electronic vital signs equipment
Recoding and reporting information                            Weight: pounds and kilograms
Recognizing cardiac arrest

                   CARDIAC SKILLS                     EXP.                     CARDIAC SKILLS                  EXP.
Assessment:                                                   Angina (Acute and Chronic)
   Capillary Refill                                           Assessment/treatment of orthostatic BP
   Edema                                                      Assessment: abnormal heart tones
   Heart tones                                                Anti-embolic devices

                 ENDOCRINE SKILLS                     EXP.                    ENDOCRINE SKILLS                 EXP.
Caring for the Diabetic Patient: Skin
                                                              Hypo/Hyperglycemia: recognition/treatment
Diabetes management: capillary blood glucose
                                                              Hormone therapy
Diabetic teaching                                             Insulin administration

              GASTROINTESTINAL SKILLS                 EXP.                 GASTROINTESTINAL SKILLS             EXP.
Administration: tube feedings                                 I&O: Shift volumes and totals
Assessment: bowel sounds                                      Identifying abnormalities
Total parenteral nutrition (TPN), care of                     Ileostomy/colostomy care
Abdominal wounds/infections, care of                          Insertion /maintenance feeding tubes (NG)
I &O: Marking/measurement of amounts of urine,
                                                              Stool tests
gastric fluid, NG drainage, emesis, diarrhea

               GENITOURINARY SKILLS                   EXP.                 GENITOURINARY SKILLS                EXP.
Catheter: insertion/care                                      Interpretation of UA lab values
Chronic renal failure, care of                                Managing suprapubic catheter
Collection of urine specimens                                 Managing urostomy
Dialysis, care of                                             Placing condom catheter
Fluid and electrolyte assessment

                  HYGIENE SKILLS                      EXP.                      HYGIENE SKILLS                 EXP.
Bathing (shower/tub)                                          Peri-care
Bathing/daily hygiene                                         Pressure/friction reduction beds/mattresses
Foot care: impaired circulation/sensation, foot
                                                              Recording and reporting hygiene/skin breakdown
cradles, heel protection

                                     developed by Beth Nash, RN from
Incontinence care                                              Risk factors for skin breakdown
Observation, recording and reporting pressure
                                                               Shaving: precautions/technique
points for redness of breakdown
Oral Care: regular/soft diet, NPO, comatose,
                                                               Use of bath/shower boat/shower chair
denture care

               INFECTION CONTROL                       EXP.                  INFECTION CONTROL               EXP.
Brody substance isolation                                      Protective/reverse isolation
Disposal of sharps                                             Supply/equipment disposal
Handwashing                                                    TB precautions
Infectious/hazardous waste disposal                            Use of CPR mask/bag
MRSA precautions                                               Use of disposable thermometer
PPE: Gloves, gown, mask, goggles

               INTRAVENOUS SKILLS                      EXP.                   INTRAVENOUS SKILLS             EXP.
Administering blood and blood products                         Set up and monitoring for TPN
Administering fluids on continuous IV pumps                    Setting Up and monitoring PCA
Changing IV dressings                                          Starting IV
Changing IV sites                                              Using PICC, Hickman, Triple Lumen catheters
Changing IV tubing                                             Venipuncture for specimen
Obtaining central venous/peripheral venous blood

          MEDICATION ADMINISTRATION                    EXP.              MEDICATION ADMINISTRATION           EXP.
Cimetidine (Tagamet)                                           Lorazepam (Ativan)
Diazepam (Valium)                                              Morphine
Digoxin (Lanoxin)                                              Naloxone (Narcan)
Duramorph                                                      Nitroglycerine
Furosemide (Lasix)                                             Pentobarbital
Heparin                                                        Phenytoin (Dilantin)
Insulin                                                        Potassium Chloride

            MUSCULOSKELETAL SKILLS                     EXP.                 MUSCULOSKELETAL SKILLS           EXP.
Amputation, care of                                            Joint/bone disorders, care of
Arthroscopy/arthrotomy                                         Skeletal and skin traction
Braces                                                         Slings/Splints
Casts                                                          Total hip replacement, care of
Collars                                                        Total knee replacement, care of
Crutch walking/walkers                                         Traction

               NEUROLOGICAL SKILLS                     EXP.                  NEUROLOGICAL SKILLS             EXP.
Alzheimer’s, care of                                           Head Injury, care of
Assessment: Neurological                                       Parkinson’s, care of
Autonomic Dysreflexia, care of                                 Pre / Post Neurological Surgery
Caring for Patient with:                                       Seizure Precautions
  Chronic C.V.A / T.I.A                                        Spinal Cord Injury, care of
  CNS Infections                                               Using Glascow Coma Scale
   Halo Traction

                                      developed by Beth Nash, RN from
                 NUTRITIONAL SKILLS                    EXP.                   NUTRITIONAL SKILLS                   EXP.
Aspiration precautions                                         Nourishments
Counting calories                                              NPO
Estimating intake                                              Recording and reporting nutritional information
Feeding patients                                               Setting up for meals
Fluid restriction

             PATIENT SAFETY/ACTIVITY                   EXP.               PATIENT SAFETY/ACTIVITY                  EXP.
Ambulating with/without device                                 Recognizing Abuse: Emotional, physical, substance
Application/documentation of restraints: Belt,
                                                               Reporting broken equipment
ankle, wrist, vest
Bed operation                                                  ROM Exercises
                                                               Transfer to bed, WC, commode with or without
Determining need for additional help
Determining patient ID                                         Turning and positioning
Handling hazardous materials                                   Use of alarms (bed, patient, unit)
Identifying/responding to safety hazards                       Use of call light
Maintaining clean/orderly work space                           Use of Hoyer Lift (Dextra/Maxi)
Patient Safety module                                          Use of seizure pads
Proper body mechanics                                          Use of wheel locks

               RESPIRATORY SKILLS                      EXP.                    RESPIRATORY SKILLS                  EXP.
Assessing the respiratory system including:                    Care of ventilator-dependent Patient:
   Breath sounds                                                   Suctioning: length of time suctioning
   Breathing Pattern / Effort                                      Hyperventilation
   Cough effort                                                    Ventilator settings
   Skin and nail bed color                                         Documentation
   Sputum (color/character)                                    Caring for a patient with:
Care and maintenance of:                                           Respiratory failure
   Acute airway                                                    Respiratory infections
   Nasopharyngeal airway                                           Status Asthmaticus
   Oropharyngeal airway                                            Respiratory Distress syndrome
Administering and monitoring O2 including:                         Pulmonary edema
   Nasal cannula                                                   Pulmonary emboli
   Mask                                                            Tension pneumothorax
   O2 Sats                                                         Tracheostomy
Demonstrating proper use of Ambu Bag                           Use of Incentive Spirometer

                                      developed by Beth Nash, RN from

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