Competency Checklist - RN

Skill: End of Shift/Documentation Departm

ent:
Name: Position:

Criteria Comments
1) Check the doctor's order.
2) Confirm the patient’s identity using two patient identifiers.
3) Take patient weight & DOCUMENT (if ordered)
Prepares the necessary supplies:
4) Washes hands
5) Dons non-sterile gloves
6) Explains the procedure to the patient
7) Provide privacy.
8) Provide adequate lighting.
9) Make sure VS were charted
10) DOCUMENT Accuchecks on the Diabetic Flowsheet
11) Document a PAIN SCALE RATING on flowsheet: ( at least
once, even if a “0” )
1) Each time you medicated the patient for pain
2) If you interviewed total I&O for shift
3) @ 11pm if 24-hr I&O
12) Complete the MEDSURG Flowsheet (or SNF flowsheet for SNF
Patients)
13) DOCUMENT IV site assessments and tubing and dressing
change dates and change on MED-SURG flowsheet
14) DAR Charting: Write a progress note
15) Update ICR, Education flowsheet and/or problem list and
sign ICR signature sheet (at least once)
16) Check that all handwritten meds on MAR have been
double checked and initialed (esp. one-time meds)
17) Check that all your meds, PCAs, and IVF have been given
and signed out on the MAR
18) DOCUMENT on the PCA flowsheet every 2-4 hours for PCA
Patients
19) Co-Sign the PCA flowsheet with another Rn at the shift
change and any time the dose was changed or a bolus was
 given.
20) Fill in the IV slip:
a) Each time a new IV site started
b) Changed a central line dressing
c) DC’D an IV or central line.
RESTRAINT PATIENTS:
21) DOCUMENT on the restraint flowsheet as indicated for
patients in restraints
22) Write a progress note on the restraint flowsheet
addressing patient safety for any patient being restrained
23) Obtain a new order every calendar day for a patient being
restrained
NEW ADMISSIONS:
24) Complete the computerized database and put a copy on the
chart for a new admission.
25) Initiate the ICR problem list and education record for new
admits
26) Initiate the medication reconciliation form for new admits
27) Offer vaccine, smoking cessation info, or CHF information to
the appropriate patients and document information given on
the Education Record
28) Put the vaccine standing orders in the chart if indicated
29) Make sure the information on the Discharge form matches
the progress note and includes the Discharge time, mode and
destination on both
30) Complete the Medication Reconciliation form for discharge
meds
31) Review and Sign off all new orders with the Date, Time
and Initials
32) Complete chart check for shift (24hr check on night shift)

ρ Has satisfactorily completed the above criteria and has demonstrated competency in those
areas.
Date Met: ______/______/______

ρ Has NOT met criteria. Action plan described on back of page; reviewed by Employee and
Instructor/Manager.
Date Not Met: ______/______/______

___________________________________ _______________________________
Instructor Signature date Employee Signature