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RN Supervisor
RN Supervisor
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
Universal Precautions
No Experience
Limited Experience
Experienced
Highly Skilled
Working with Patients in Isolation
Working with Patients in Restraints
Patient/Family Teaching
Patient Identification
Specialty Beds
End of Life Care/Palliative Care
Knowledge of "Do Not Use Abbreviations"
Do you have Charge/Supervisor Experience?
Knowledge of Current Joint Commission National Patient Safety Goals
Knowledge/Familiarity with HCAHPS Scores
Acute Care/Hospital
No Experience
Limited Experience
Experienced
Highly Skilled
Durable Medical Equipment (DME)
Managed Care
SNF/Long Term Care
Home Health
Hospice
Outpatient
Physician Office
Understanding of Health Care Economics and Health Care Policies as it applies to Delivery of Patient Care
No Experience
Limited Experience
Experienced
Highly Skilled
Concepts of Capital Budgeting
Department/Unit Budgeting
Recruitment Techniques
Interview Techniques
Labor Laws Pertaining to Hiring
Orientation of New Employees
Knowledge of Quality Improvement/Performance Improvement Tools
Patient Safety
Workplace Safety
Promotion of Interdepartmental Communication
Performance Management
Staff Development
Coaching and Mentoring
Project Management
Business Development
Developing Strategic Plans
Developing Operational Plans
Cultural Competence
Personal Growth and Development
Ethical Behavior and Practice
Professional Association Involvement
Conflict Management
Team Dynamics
Mediation/Coaching
TJC Standards
OSHA Standards
Risk Management/Service Utilization
Local Department of Health
State Department of Health
Sitter Services
Age Specific Competencies
No Experience
Limited Experience
Experienced
Highly Skilled
Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
By signing below, I attest that the information contained above is accurate to the best of my knowledge, and that I am the individual completing this form. I further authorize the Company to release this Qualification List to the Client facilities in accordance with the consideration of employment as a Healthcare Professional with those facilities.
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