CNA Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

Specialty areas

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Experience in these care areas: *

Acute Care Hospital	1234
Long Term Care	1234
Rehabilitation Center	1234
Home Health/Private Duty	1234
Hospice	1234

Clinical tasks

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Assist in clinical tasks as delegated by licensed nurse: *

Vital signs (Temp, HR, B/P, Respirations)	1234
Manual B/P (using cuff and stethoscope)	1234
Oxygen saturation	1234
Ambulation with 1-2 assist	1234
Ambulation with walker	1234
Turn and reposition q 2 hrs	1234
Fingerstick glucose checks	1234
Indwelling urinary catheter care (Foley)	1234
Empty urinary catheter drainage bag	1234
General review of skin condition	1234
Reporting unusual or concerning information to the nurse	1234
Empty surgical drains (e.g. Jackson Pratt/JP drain)	1234
Calculate and record intake and output values	1234
Application of oxygen via nasal cannula	1234
Proper disposal of soiled linen	1234
Incontinence care (urinary and bowel)	1234
Proper transfer technique (bed to chair, bed to wheelchair, etc.)	1234
Provide privacy during routine care (use of curtain, close door, etc.)	1234
Use of military time in documentation	1234
Perform daily weights	1234
Collect specimens (urine, stool, sputum)	1234
Administer enema (under supervision of nurse)	1234
Application and removal of anti-embolic stockings (e.g. TED hose)	1234
Basic Life Support (chest compressions, rescue breathing, etc.)	1234
Therapeutic communication techniques for combative patients/residents	1234
Ostomy care (under supervision of nurse)	1234

Activities of Daily Living

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Assist patient/resident with the following ADLs: *

Bed bath	1234
Shower	1234
Bath tub	1234
Perineal care (male and female)	1234
Voiding (urinal, bedpan, bedside commode, toilet)	1234
Grooming (brush/comb hair, shaving, etc.)	1234
Oral care (brush teeth, dentures, etc.)	1234
Application of hearing aids and glasses	1234
Set up of meal tray (opening items, etc.)	1234
Assisting with eating/drinking at meal times	1234
Linen changes (occupied and unoccupied beds)	1234
Passive range of motion exercises	1234
Foot care (as directed by nurse)	1234
Hand and nail care (as directed by nurse)	1234
Massage (as directed by nurse)	1234
Encourage use of adaptive equipment (cane, walker, trapeze bar, etc.)	1234
Use of non-skid footwear	1234

Equipment

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Use of the following equipment to assist in ADLs and other tasks: *

Vest restraint (e.g. Posey)	1234
CPM machine	1234
Glucometer (please specify brands)	1234
Mechanical lift (e.g. Hoyer)	1234
Gait belt	1234
Call light/bell	1234
Electronic B/P machine	1234
Oxygen saturation monitor	1234
Wrist/ankle restraints	1234
Nasal cannula	1234
Portable O2 tank	1234
Wheelchair	1234
Reclining chair	1234
Various beds (including changing height, using for weight measurement, etc.)	1234
Protective devices (skin protectors for heels, elbows, coccyx, etc.)	1234

Precautions

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Implement and follow these precautions: *

Aspiration	1234
Bleeding	1234
High risk for falls	1234
Elopement	1234
Suicide	1234

General & Other

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Implements and correctly follows: *

Proper body mechanics	1234
Technique to preserve respect and dignity for patient/resident	1234
Introduction of self prior to providing care	1234
Preparing thickened liquids	1234
Various special diets (e.g. diabetic, reduced sodium, pureed, clear liquids, etc.)	1234
Post-mortem care	1234

Infection Control

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Implementation and management of: *

Hand hygiene	1234
Precautions and associated PPE (transmission, contact, airborne, droplet)	1234
Negative-pressure room	1234
Prevention and protocols for HAIs (CAUTI, CLABSI, VAP)	1234
Prevention and protocols for MRSA, C.Diff, Sepsis, etc.	1234

Age Specific

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Care of the following age groups: *

Infant (birth to 1 year)	1234
Toddler (ages 1-3 years)	1234
Preschooler (ages 4-5 years)	1234
Childhood (ages 6-12 years)	1234
Adolescent (ages 13-21 years)	1234
Young adults (ages 22-39 years)	1234
Adults (ages 40-64 years)	1234
Older adults (ages 65-79 years)	1234
Elderly (ages 80+ years)	1234

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. *