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CNA
CNA
Name
First
Last
Email
Phone
Date
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
Experienced
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
Skills
No Experience
Limited Experience
Experienced
Highly 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
CPR
Crutch walking - Assist patient
Dangling patient
Diabetic testing
Dietary restrictions
Documentation - Vital signs, I&O
Documentation of patient's belongings
Douches
Elastic stockings (AE hose)
Elimination check and record
Enemas, rectal tubes, Harris flush
Fall precautions
Feed patient
Foley catheter care and emptying
Foodboard
Glucometer
Hand hygiene
Height - Measure and record
Intake and output - Measure and record
Orthostatic blood pressure
Transfers
Use of assistive devices
Vital signs
Weight - Measure and record
Electronic documentation
Specimen Collection
No Experience
Limited Experience
Experienced
Highly Skilled
Routine urine
Clean catch
12 and 24 hour specimen
Stool
Culture
Sputum
From Foley catheter
Infection Control Precautions
No Experience
Limited Experience
Experienced
Highly 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
Restraints
Skin care
Signature
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