PERFORMANCE CHECKLIST

APPLICATION OF HOT WATER BAG

NOT
PROCEDURE DONE SCORE
DONE
2
1. Gather the materials.
3
2. Check the temperature of water.
3
3. Fill the bag at least 2/3 full.
2
4. Expel the air
3
5. Secure the cover
3
6. Dry the bag and test it for leakage
3
7. Wrap the bag with dry towel and secure it.
3
8. Identify the patient and explain the procedure
2
9. Apply the hot water bag on the treatment site.
2
10. Check every now and then.
2
11. Remove bag after treatment.
2
12. Document the procedure done.
TOTAL 30

Name: ____________________ Score: _______________

Section: ___________________ Date: _______________

Instructor:__________________