Home Health Care Competency Self Assessment

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Austen Lloyd
9 years ago
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1 Home Health Care Competency Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date General Skills Advanced directives Patient/family teaching Lift/transfer devices Specialty beds Restrictive devices (restraints) End of life care/palliative care Skin/wound assessment & care Diabetic care & education Blood Glucose Monitoring (BGM) General nursing assessment Recognizing failure to thrive across the lifespan Monitoring of vital signs Monitoring of intake/output Monitoring of weight Cardiac/respiratory arrest/cpr adult Cardiac/respiratory arrest/cpr pediatric or infant Documentation of skilled care (written) or computerized Medicare 485/486 forms National Patient Safety Goals Accurate patient identification Effective communication Interpretation & communication of lab values Medication administration Medication reconciliation Anticoagulation therapy Pain assessment & management Infection control (nosocomial/community-acquired) Anti-infective therapy (antibiotics, antivirals, antifungals) Universal precautions Awareness of HCAHPS Cross Country Healthcare, Inc. Rev. 09/12 F0027 Home Health Care 1 of 6

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date General Skills

2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) General Skills - cont. Isolation Minimize risk falls Prevention of pressure ulcers IV Therapy Starting & maintaining peripheral IVs Blood draw: venous Central line care (includes PICC/Groshong/Hickman) Blood draw: central line Care & management of ports Care & management of nonvascular devices (epidural, intrathecal) TPN & lipids Administration of blood and blood products Administration of chemotherapy Monitoring of chemotherapy (does not initiate) Infusion pumps Cardiac Cardiovascular assessment Clinical identification of dysrythmias (AP check for rate & rhythm) Hypertension Coronary Artery Disease (CAD) Acute MI Post Coronary Artery Bypass Graft (CABG)/valve CHF Aneurysm (thoracic or abdominal) Pre-post surgery Medication Administration/Patient Teaching Antidysrhythmics (i.e., betablockers, calcium channel blockers & cardiac glycosides) Antihypertensives Vasoactive drugs (NTG) Diuretics (i.e., lasix, dyazide) Respiratory Assessment/auscultation of lung sounds Incentive spirometry Principles of chest percussion Establishing an airway Cross Country Healthcare, Inc. Rev. 09/12 F0027 Home Health Care 2 of 6

line care (includes PICC/Groshong/Hickman) 0 1 2 3 4 5 Blood draw: central line 0 1 2 3 4 5 Care & management of ports 0 1 2 3 4 5 Care & management of nonvascular devices (epidural, intrathecal) 0 1

3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Respiratory - cont. Asthma COPD Pulmonary hypertension Tracheostomy Lung cancer Pulmonary emboli Medication Administration/Patient Teaching Aminophylline Bronchodilators (Bronkosol/Brethine) Expectorants Inhaled medications (proventil/anticholinergics/steroids/mucolytics) Neurology Assessment of neuro signs Seizure precautions Halo traction Coma Cerebral tumors Seizure activity Spinal cord injury/paralysis (para/quad) TBI (Traumatic Brain Injury) TIA s Stroke (CVA) hemiparesis Alzheimer s Disease Meningitis Multiple sclerosis Parkinson s disease ALS (Amyotrophic Laterial Sclerosis) Medication Administration/Patient Teaching Cortocosteroids Anticonvulsant MAOIs Antidyskinetics Skeletal muscle relaxants Dopamine (blockers & stimulants) Cross Country Healthcare, Inc. Rev. 09/12 F0027 Home Health Care 3 of 6

Aminophylline 0 1 2 3 4 5 Bronchodilators (Bronkosol/Brethine) 0 1 2 3 4 5 Expectorants 0 1 2 3 4 5 Inhaled medications (proventil/anticholinergics/steroids/mucolytics) 0 1 2 3 4 5 Neurology

4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) GI / GU NG tube Long term feeding tube (Keofeed, Dobhoff) PEG/gastrostomy tube Tube feeding Drainage tubes (surgical & non-surgical) G.I. bleed Colostomy/ileostomy care Ileal conduit G.U. irrigations Suprapubic catheter Shunts & fistulas Straight catheterization Self catheterization Incontinence Peritoneal dialysis Hemodialysis Gynecology Endometriosis Self breast exam Mastectomy Hysterectomy Orthopedic Total joint replacements (knee/hip/shoulder) Crutch walking Assistive devices Arthroscopy/arthrotomy TENS unit Arthritis Amputation Casts Fractures Cross Country Healthcare, Inc. Rev. 09/12 F0027 Home Health Care 4 of 6

bleed 0 1 2 3 4 5 Colostomy/ileostomy care 0 1 2 3 4 5 Ileal conduit 0 1 2 3 4 5 G.U.

5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Maternal - Child Care Assessment & care of complicated pregnancy Breast feeding Homecare of postpartum mother Healthy baby Newborn Care Bulb suctioning Cord & circumcision care Phototherapy NG feedings Pediatrics Medication calculation for pedi dosing Use of croup tent Oxyhood Care of the Pediatric Patient with: Asthma Bone marrow transplant Bronco-pulmonary dysplasia Cardiac surgery Cystic fibrosis Epiglottiditis Near drowning Overdose/poison ingestion Post harrington rod insertion Respiratory Distress Syndrome (RDS) Reye s syndrome Sickle cell disease Spina bifida Use of Equipment for All Age Groups Cardiac monitors Wound VAC Apnea monitors O2 administration (NC/mask) Ultrasonic nebulizer Ventilators Software Programs MeDecision TILE OASIS Cross Country Healthcare, Inc. Rev. 09/12 F0027 Home Health Care 5 of 6

Phototherapy 0 1 2 3 4 5 NG feedings 0 1 2 3 4 5 Pediatrics Medication calculation for pedi dosing 0 1 2 3 4 5 Use of croup tent 0 1 2 3 4 5 Oxyhood 0 1 2 3 4 5 Care of the Pediatric Patient with:

6 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Age Specific Competencies Newborn/neonate (birth-30 days) Infant (31 days-1 years) Toddler (2-3 years) Preschool (ages 4-5 years) School age (ages 6-12 years) Adolescents (ages years) Young adult (ages years) Adults (ages years) Older adult (ages years) Elderly (80+ years) Please list any Additional Skills: Additional training: Additional equipment: Fax to: The information on this and all preceding pages is true and correct. Signature Date 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0027 Home Health Care 6 of 6

4 5 Young adult (ages 22-39 years) 0 1 2 3 4 5 Adults (ages 40-64 years) 0 1 2 3 4 5 Older adult (ages 65-79 years) 0 1 2 3 4 5 Elderly (80+ years) 0 1 2 3 4 5 Please list any Additional Skills: 1. 2. 3. 4. Additional training: 1.

Pediatric Competency Self Assessment

Pediatric Competency Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm