• Date Format: MM slash DD slash YYYY
  • Self-Assessment Rating Scale

    No Experience
    Theory or observation only during the past 12 months

    Limited Experience
    Performed less than 12 times within the past 12 months and may need a review

    Performed at least once per month within the past 12 months and may need minimal assistance

    Highly Skilled
    Performed on at least a weekly basis over the past 12 months; proficient
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Assist with admission of patient
    Assist with ambulation
    Assist with bedpan/urinal/commode
    Back rubs/back care
    Basic medical esepsis
    Bathing - Complete/partial/sitz
    Bed cradles
    Bed making - Occupied/unoccupied/surgical
    Bed rails - When/how to use them
    Cast care
    Charting/checklist/graphic charts
    Compresses - Warm/cold
    Coughing/deep breathing
    Crutch walking - Assist patient
    Dangling patient
    Diabetic testing
    Dietary restrictions
    Documentation - Vital signs, I&O
    Documentation of patient's belongings
    Elastic stockings (AE hose)
    Elimination check and record
    Enemas, rectal tubes, Harris flush
    Fall precautions
    Feed patient
    Foley catheter care and emptying
    Hand hygiene
    Height - Measure and record
    Intake and output - Measure and record
    Orthostatic blood pressure
    Use of assistive devices
    Vital signs
    Weight - Measure and record
    Electronic documentation
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Routine urine
    Clean catch
    12 and 24 hour specimen
    From Foley catheter
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Standard universal precautions
    Reverse isolation
    TB/airborne precautions
    MRSA/VRE precautions
    Nourishment for patients
    Observing patients
    Oral hygiene
    Patient safety standards/precautions
    Perineal care
    Prosthetic devices (care of dentures, contact lenses, etc.)
    Range of motion exercises
    Reporting changes of patient condition
    Reporting/recording of patient's pain level
    Skin care
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