Patient Care Tech Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

PLEASE RATE YOUR LEVEL OF SKILLS & FREQUENCY OF PERFORMANCE FOR THE FOLLOWING PROCEDURES/SKILLS:

Proficiency

I have never done the stated task.
I have performed the task/skill infrequently; I require more experience/practice to feel comfortable and proficient.
I have performed the task/skill several times and feel moderately comfortable functioning independently but would require a resource person nearby.
I have performed the task/skill frequently and would feel very comfortable and proficient performing it without supervision or practice.

Frequency

VITAL SIGNS (TAKE AND RECORD) *

ENVIRONMENT *

AMBULATING *

TRANSFER TECHNIQUE *

POSITIONING/TURNING *

PERSONAL CARE *

NUTRITION/HYDRATION *

	SKILL		FREQUENCY
Encourage Fluids per Patient's Orders
Types of Diet
Assist in Feeding
Feeding Techniques
Measure and Record Intake and Output

INFECTION CONTROL *

ELIMINATION *

	SKILL		FREQUENCY
Bed Pan/Urinal and Fracture Pan
Bedside Commode
Measure and Record Output
Foley Catheter Care
External Catheter Care/Placement
Enemas
Urine Specimen Collection
Stool Specimen Collection
Sputum Specimen Collection

SAFETY DEVICES *

OXYGEN THERAPY *

	SKILL		FREQUENCY
Cannula/Mask Placement

OBSERVATIONS/REPORTING/DOCUMENTATION *

ELECTRONIC DOCUMENTATION *

AGE SPECIFIC COMPETENCIES *

	SKILL		FREQUENCY
Newborn/Neonate (birth to 30 days)
Infant (31 days to 12 months)
Toddler (1-3 years)
Preschooler (3-5 years)
School age children (5-12 years)
Adolescents (12-18 years)
Young adults (18-39 years)
Middle adults (39-64 years)
Older adults (64-79 years)
Elderly adults (80+ years)

Attestation

ATTESTATION: *

I certify that the information provided above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *