CNA

This checklist was electronically signed on (Today’s date)

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency Scale:

1 . No Experience

2 . Need Training

3 . Able to perform with supervision

4 . Able to perform independently

PATIENT RIGHTS

VITAL SIGNS AND WEIGHTS

USE OF ELECTRONIC VS EQUIPMENT

SCALE USE

GI /GU

ADMINISTERING ENEMAS

NUTRITION

SPECIMENS

COLLECTING URINE

Clean Catch
24 Hour

HYGIENE /SKIN

Risk Factorsfor Skin Breakdown
Observing Pressure Points for Redness or Breakdown

BATHING /DAISY HYGIENE

Use of Pressure and Friction Reduction Devices:

Infection Control

Proper use of Specific Barrier, Methods:

Safety and Activity

Application of Restraints:

New Admissions and Transfers:

Inventory and Disposition of Belongings, Useof Checklist
Room Orientation, Call Bell

Post-op Patients:

Maintaining 02 Therapy:

Preparation For and Transfer to SNF:

Removing /Replacing:

Antiembolic Stockings
Sequential Stockings

Communication

Communicating to RN:

Recording and Reporting:

1 & 0:

Shift Volumes and Totals
Marking and /or Measuring Amount of Urine, Gastric Fluid, NG Drainage, Emesis, Diarrhea

Unit Activity

AGE SPECIFIC COMPETENCIES

I hereby certify that ALL information I have provided on this skills checklist and all other documentation is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Communicates and obtains information while respecting the rights and privacy and confidentiality of information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Involves the patient and family and respects their role in determining the nature of care to be provided, including Advance Directive
Complies with nursing staff responsibility included in the hospital policy related to Organ Donation
Meets patient and families needs regarding communication, including interpreter services
Provides accurate information to patient and families in a timely manner

BP, including Orthostatic
Pulse, Radia
Temperature, Oral
Temperature, Rectal
Temperature, Axillary
Temperature, Tympanic
Respirations
Weight, Pounds and Kilograms
Recognizing Cardiac Arrest
Activating Code Team
Bringing Emergency Equipment to Room
Providing Appropriate Code Support
Placing and Removing Bed Pan
Clamping Catheter
Emptying Foley Bag
Placing Condom Catheter
Emptying and Replacing Ostomy Bag (Established Ostomy)

Estimating Intake
Setting up for Meals
Feeding Patients
Aspiration Precautions
Nourishments
Counting Calories
Fluid Restriction
NPO

Bathing (Shower /Tub /Arjo)
Oral Care, Including Patients who are NPO,Comatose, Patients with
Pen Care
Foot Care for Patients with Impaired Circulation or Sensation
Incontinence Care
Shaving and Precautions
Reducing Pressure and Friction

Special Beds/Mattresses
Heels and Elbow Protection
Foot Cradles
Use of Shower Chair
Use of Bath/Shower Boat

Automatic BP machine (Dynamap)
Electronic Thermometer
Applying Oximeter

Collecting Stool
Collecting Sputum
Labeling Specimens and Preparing for Transport

Reverse Isolation
Body Substance isolation
TB Precautions
MRSA Precautions
Hand Washing
Infectious/Hazardous Waste Disposal
Supply/Equipment Disposal
Use of Disposable Therrnomete
Use of CPR Mask/Bag

Determining Patient ID
Identifying Safety Hazards
Determining Need for Additional Help
Assessing Safety and ADL Needs
Recognizing Abuse: Substance, Physical, Emotional, etc
MaintainingClean, Orderly Work Area
Disposing of Sharps
Handling Hazardous Materials
Proper Body Mechanics
ROM Exercises
Transferring to Bed,WC, Commode, etc
Turning and Positioning
Patient Safety Module
Reporting Broken Equipment
Responding to Safety Hazards
Use of HoyerLift (Dextra /Maxi)
Bed Operation
Use of Wheel Locks
Use of Alarms: Bed, Patient, Unit
Use of CaIl Light
Documenting Use of Restraints
Use of Transfer Belt
Use of Gait Belt for Ambulation
Use of Seizure Pads

Transferring into Bed
Call Bell
Assist with Turns
ROM Exercises

Replacing Mask or Nasal Caunula if Needed
Notifying Nurse of Problems
Basic Comfort Measures

Early Bath
Preparing Belongings
Preparingfor and Explaining Routinesto Patient
Post Mortem Care
Use ofIncentive Spirometer

Using Appropriate Abbreviations
Identifying UnusuaI Patient Incidents that Require Reporting
Reinforcing RN Teaching With Patient
Selecting and Using Forms Appropriately
Using Alternate Communication Tools /Devices

Changes in Patient Condition
Patient Needs, Complaints and Concerns
Unusual Incidents

Vital Signs
Bathing /Hygiene
Turning and Repositioning
Ambulation and Activity
Diet intake, Calorie Count
Bowel Movements

Report Abnormal Findings
Bowel Function
Bladder Function

Tap Water
Fleets
Return Flow

Gloves
Gown
Mask / Goggles

Belt Including Seat Belt
Wrist/Ankle
Vest

Identifying Unusual Incidents on the Unit that Require Reporting
"Locating and Using Appropriate Reference Materials: Hospital, Patient Care and"
Charging for Patient Care Items
Completing Risk Management Reports as Needed
Obtaining Needed Supplies and Equipment
Reporting and Following up on Faulty Equipment and Supplies
Using Telephone System

Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)
Elderly (ages 80+ years)