Skills Checklist - Hospice RN - Origin Travel Nurses

Name
First Last
Phone
Email
WORK SETTING*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Home Hospice
Inpatient Hospice
Pediatric Hospice
Home Health/Hospice Setting
ASSESSMENT*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Intake Assessment
Assessment Interview
Physical Exam
Coping Status
Environmental Status
PLAN OF CARE*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Set Goals with Patient/Family
Collaborate with Other Team Members
Collaborate with Other Team Members

SYMPTOM MANAGEMENT*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Urgent Assessment of Symptoms
Reduce Symptoms to Level Acceptable to Patient
Report Symptoms/Management to Provider
Treat Underlying Cause
Severity Scale
Management of Nausea
Management of Constipation
Management of Fatigue
Anorexia/Cachexia
Restlessness
Educate Family of Symptom Management

PAIN MANAGEMENT*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Identify Source of Pain
Pain Severity
PAINAD Scale for Non-verbal Patient
Reduce Pain to Level Acceptable to Patient
WHO 3-Step Ladder
Non-Pharmacological Management of Pain
Pharmacological Management of Pain
Effects of Pharmacological Treatment
Nociceptive/Neuropathic/Mixed Pain
Management of Nociceptive Pain
Management of Neuropathic Pain
Educate Family on Pain Management

WOUND CARE*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Positioning Techniques
Bed/Support Surface Selection
Pressure Ulcer Staging/Management
Response to Treatment
Evaluate Factors that Impede Healing
Educate Family on Positioning/Shearing

PEDIATRICS*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Developmentally Appropriate Assessment
Parental/Sibling Support
Pediatric Support Team Collaboration

MEDICATION ADMINISTRATION*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Equianalgesic Conversion Formula
Titration of Opioids
IV Pump Management
Evaluate Effectiveness of Medications
Family Management of Medications
Disposal of Medications

COMPLIANCE*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Scope and Frequency of Services
Medicare/State Regulations for Hospice
Document Progression of Decline
DME Authorization & Documentation of Need/Order
OASIS-C

PROFESSIONAL KNOWLEDGE AND SKILLS*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Identify Source of Suffering
Palliative Care Philosophy
Patient/Family Directs Goals of Care
Maximize Quality of Life
Cultural Diversity
National Patient Safety Goals/Core Measures
Supervision of Ancillary Staff
Fall Risk Assessment/Prevention
Infection Prevention
Isolation Precautions
Interpretation and Communication of Lab Values
Electronic Documentation
Automated Medication Dispensing Systems

Age Group Experience*

Do you speak any languages other than English?*
- No
If yes, enter languages above, separated by commas.
Confirmation*
- I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
Signature
Date
MM slash DD slash YYYY

Origin Travel Nurses has earned the Joint Commission's Gold Seal of Approval

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Set Goals with Patient/Family
Collaborate with Other Team Members
Collaborate with Other Team Members

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Developmentally Appropriate Assessment
Parental/Sibling Support
Pediatric Support Team Collaboration