Skills Checklist – Hospice RN

Skills Checklist – Hospice RN

• Name
  
  First
  
  Last
• Phone
• Email
  
• WORK SETTING*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Home Hospice
  Inpatient Hospice
  Pediatric Hospice
  Home Health/Hospice Setting

• ASSESSMENT*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Intake Assessment
  Assessment Interview
  Physical Exam
  Coping Status
  Environmental Status

• PLAN OF CARE*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Set Goals with Patient/Family
  Collaborate with Other Team Members
  Collaborate with Other Team Members

• SYMPTOM MANAGEMENT*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Urgent Assessment of Symptoms
  Reduce Symptoms to Level Acceptable to Patient
  Report Symptoms/Management to Provider
  Treat Underlying Cause
  Severity Scale
  Management of Nausea
  Management of Constipation
  Management of Fatigue
  Anorexia/Cachexia
  Restlessness
  Educate Family of Symptom Management

• PAIN MANAGEMENT*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Identify Source of Pain
  Pain Severity
  PAINAD Scale for Non-verbal Patient
  Reduce Pain to Level Acceptable to Patient
  WHO 3-Step Ladder
  Non-Pharmacological Management of Pain
  Pharmacological Management of Pain
  Effects of Pharmacological Treatment
  Nociceptive/Neuropathic/Mixed Pain
  Management of Nociceptive Pain
  Management of Neuropathic Pain
  Educate Family on Pain Management

• WOUND CARE*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Positioning Techniques
  Bed/Support Surface Selection
  Pressure Ulcer Staging/Management
  Response to Treatment
  Evaluate Factors that Impede Healing
  Educate Family on Positioning/Shearing

• PEDIATRICS*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Developmentally Appropriate Assessment
  Parental/Sibling Support
  Pediatric Support Team Collaboration

• MEDICATION ADMINISTRATION*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Equianalgesic Conversion Formula
  Titration of Opioids
  IV Pump Management
  Evaluate Effectiveness of Medications
  Family Management of Medications
  Disposal of Medications

• AFTER DEATH*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Family/Cultural Rituals/Rites
  Patient Care after Death
  Coordinate Mortuary Services
  Bereavement Services

• COMPLIANCE*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Scope and Frequency of Services
  Medicare/State Regulations for Hospice
  Document Progression of Decline
  DME Authorization & Documentation of Need/Order
  OASIS-C

• PROFESSIONAL KNOWLEDGE AND SKILLS*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Identify Source of Suffering
  Palliative Care Philosophy
  Patient/Family Directs Goals of Care
  Maximize Quality of Life
  Cultural Diversity
  National Patient Safety Goals/Core Measures
  Supervision of Ancillary Staff
  Fall Risk Assessment/Prevention
  Infection Prevention
  Isolation Precautions
  Interpretation and Communication of Lab Values
  Electronic Documentation
  Automated Medication Dispensing Systems

• GENERAL SKILLS – TYPES OF AUTOMATED MED DISPENSING SYSTEMS:(if applicable)
• GENERAL SKILLS – TYPES OF ELECTRONIC DOCUMENTATION:(if applicable)
• OTHER SKILLS
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Skill 1
  Skill 2
  Skill 3

  (if applicable)

• Please list skills below:(if applicable)
• Age Group Experience*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Newborn (birth – 30 days)
  Infant (30 days – 1 year)
  Toddler (1 – 3 years)
  Preschooler (3 – 5 years)
  School Age (5 – 12 years)
  Adolescents (12 – 18 years)
  Young Adults (18 – 39 years)
  Middle Adults (39-64 years)
  Older Adults (64+ years)

• Do you speak any languages other than English?*
  • No

  If yes, enter languages above, separated by commas.

• Confirmation*
  • 
    I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
• Signature
• Date
  
  Date Format: MM slash DD slash YYYY