Hospice Skills Checklist

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HOSPICE CARE SETTINGS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Home care123
Inpatient hospital care123
Extended care facility123
HOSPICE CARE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Advanced directives123
Restrictive devices / restraints123
Lift / transfer devices123
Specialty beds123
Diabetes mellitus123
Blood Glucose Monitoring (BGM)123
Insulin administration123
Pain assessment & management123
Administration of narcotics / sedatives (fentanyl, Valium, Ativan, roxinal, morphine)123
Use of PCA (IV, intrathecal, epidural)123
Handling of narcotics in the home environment123
Non-pharmacologic strategies123
TENS unit123
Stages of grieving123
Spiritual care123
Death & dying counseling123
Patient & family coping skills123
Patient / family teaching & resources123
Quality of life & ethical decision making123
Death pronouncement123
After treatment (survivorship)123
National Patient Safety Goals123
Awareness of HCAHPS123
Accurate patient identification123
Effective communication123
Interpretation & communication of lab values123
Medication administration123
Medication reconciliation123
Automated Medication Dispensing System, Pyxis, Omnicell, or other123
Bar coding for medications123
Anticoagulation therapy123
Infection control123
Universal precaution123
Isolation123
Minimize risk for falls123
Prevention of pressure ulcers123
Pressure ulcer staging & care123
Wound care123
IV SKILLS:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Venipuncture for blood draw123
Peripheral IV catheter access, maintain & discontinue123
Central Venous Catheter (CVC) maintain & discontinue123
Peripherally Inserted Central Catheters (PICC)123
Groshong / Broviac / Hickman123
Ports123
Epidural catheter maintenance123
Intrathecal catheter maintenance123
Repair of torn / punctured catheters123
Declotting occluded ports or catheters123
IV THERAPY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Needleless systems123
Administration of blood & blood products123
Administration of chemotherapy123
Monitoring chemotherapy123
Administration of TPN / lipids123
ASSESSMENT EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Cardiovascular assessment123
Respiratory assessment123
Use of Incentive Spirometry (IS)123
Use of oxygen123
Application of nasal cannula123
Application of face mask123
Use of nebulizer123
Placement of oral / NT airway123
Use of ambu bag123
Pulse oximetry123
Oral and nasotracheal suctioning123
Tracheostomy123
Neuro assessment123
Seizure precautions123
Sleep assessment123
CARE OF PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Depression123
Anxiety123
Delirium123
Fatigue123
GASTROINTESTINAL:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Gastrointestinal assessment (GI)123
Nutritional assessment123
NG tube insertion, management and discontinue123
Small bore feeding tube insertion, management and discontinue123
Gastrostomy / PEG tube management123
Jejunostomy management123
Ostomy care123
CARE OF THE PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Constipation123
Nausea & vomiting123
GENITOURINARY:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Genitourinary Assessment (GU)123
Foley catheter: insert, manage & discontinue123
Nephrostomy tube123
Suprapubic tube123
Shunts & fistulas123
CARE OF PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Peritoneal dialysis123
AGE-SPECIFIC COMPETENCIES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Newborn / neonate (birth-30 days)123
Infant (31 days-1 year)123
Toddler (ages 2-3 years)123
Preschool (ages 4-5 years)123
School age (ages 6-12 years)123
Adolescent (ages 13-21 years)123
Young adult (ages 22-39 years)123
Adult (ages 40-64 years)123
Older adult (ages 65-79 years)123
Elderly (ages 80+ years)123

Attestation

ATTESTATION: *