Phlebotomist

Name
First Last
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

Venipucture Methods/Procedures

	No Experience	Limited Experience	Experienced	Highly Skilled
Interpret - Accuracy of test procedures
Interpret - Recognize and report abnormal results
Interpret - Recognize need for additional testing
Pediatrics - Finger stick
Pediatrics - Heel stick
Pediatrics - Microcapillary skin puncture
Pediatrics - Neonatal screening
Pediatrics - Venipuncture
Perform - Analysis/collection of cerebrospinal fluids
Perform - Analysis/collection (synovial, serous, semen, feces)
Perform - Bandage to site post draw
Perform - Basic and specialized specimen handling
Perform - Blood alcohol measurement
Perform - Blood cultures
Perform - Butterfly method
Perform - Decontamination of puncture site
Perform - Glucometer systems
Perform - Invert tube post draw
Perform - Monitor/document bleeding times
Perform - Patient greeting and test explanation
Perform - Positioning patient
Perform - Pressure applied to site post-draw
Perform - Proper management and use of venipuncture supplies
Perform - Proper ordering of specimen collection
Perform - Proper patient identification
Perform - Proper use and management of blood culture bottles
Perform - Proper waste disposal and use of sharps container
Perform - Specimen identification and labeling
Perform - Successful transport of specimen to lab
Perform - Syringe method
Perform - Test requisitions
Perform - Therapeutic drug monitoring
Perform - Tourniquet application and removal
Perform - Understand tube coloring system
Perform - Urinalysis - Chemical
Perform - Urinalysis - Physical
Perform - Urinalysis - Microscopic
Perform - Vacutainer method
Perform - Venipuncture site selection
Perform - Warming the puncture site
Phlebotomy complications - Edema
Phlebotomy complications - Excessive bleeding
Phlebotomy complications - Fainting
Phlebotomy complications - Failure to draw blood
Phlebotomy complications - Hematoma
Phlebotomy complications - Infection
Phlebotomy complications - Petechiae
Safety - Blood borne pathogens exposure plan
Safety - Body mechanics
Safety - Data security
Safety - Handwashing
Safety - Hazardous materials and MSDS
Safety - Patient confidentiality
Safety - Personal protective equipment
Safety - Universal precautions
Special populations - Burned areas
Special populations - Cardiac arrest patient
Special populations - Damaged veins
Special populations - Dialysis patients
Special populations - Heparin locks
Special populations - Hickman catheter
Special populations - Mastectomy
Special populations - Occluded veins
Special populations - Port-a-cath
Special populations - Scarred areas
Special populations - Sclerosed veins

Miscellaneous
No Experience Limited Experience Experienced Highly Skilled
Knowledge of radiation safety guidelines
Knowledge of TB exposure plan
Quality assurance

Age Groups

	No Experience	Limited Experience	Experienced	Highly Skilled
Toddler (1-3 yrs)
Preschool (3-5 yrs)
School age children (5-12 yrs)
Adolescents (12-18 yrs)
Young adults (18-39 yrs)
Middle adults (39-64 yrs)
Older adults (64+ yrs)

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