Area & Skill Set 	Self Assessment	Supervisor 	   Provider Reviews	Plan of Action	
	Need to 
Improve 	Meets or Exceeds 	Need to 
Improve 	Meets or Exceeds 	Need to 
Improve 	Meets or Exceeds 		
Preparing and Administering Medications								
     Administering Oral Medications								
    Preparing an injection (vial) 								
    Mixing medications to be injected 								
    Administering intradermal injections 
                								
    Administering subcutaneous injections 								
    Administering intramuscular injections 								
    Instilling eye medications								
    Instilling ear medications 								
   Reading Mantoux (PPD) test								

      								

								
Laboratory Procedures								
   Maintains CLIA-waived testing certification for all in house lab services								
   Phlebotomy and blood specimen  
   collection                                 								
   Collecting a throat swab 								
  Collecting a swab misc culture								

Cardiology and Pulmonary Medicine								
    Administering a nebulizer treatment  								
     Administering oxygen 								
    Performing a Pulmonary Function Test  								
    Performing a Peak Flow Volume reading   								
      Performing a pulse oximetry reading 								
								
Area & Skill Set 	Self Assessment	Supervisor 	   Provider Reviews	Plan of Action	
	Need to 
Improve 	Meets or Exceeds 	Need to 
Improve 	Meets or Exceeds 	Need to 
Improve 	Meets or Exceeds 		
Cardiology and Pulmonary Medicine								
     Performing a basic 12-Lead EKG 								
     Performing a Holter Monitor test 								

Special Topics								
        Assisting in applying a cast  								
       Applying an ACE bandage    								
       Measuring for axillary crutches								
       Performing a pediatric  screening 
       audiogram								
       Performing a threshold audiogram								
       Use of AED and  location of                      emergency supplies								
       								
Assisting with Office Surgery								
     Applying sterile gloves								
     Removing contaminated gloves 								
    Applying sterile dressing   								
     Changing an existing sterile dressing 								
     Removing sutures and staples    								
    Assisting with an I&D  								
    Assisting with Excisional Surgery  								
     Set up for PAP smear and/or  Endometrial Biopsy 								
     Performing skin preparation for a surgical  procedure 								
     Setting up a sterile field using a mayo 
      stand 								

     								

Area & Skill Set 	Self Assessment	Supervisor 	   Provider Reviews	Plan of Action	
	Need to 
Improve 	Meets or Exceeds 	Need to 
Improve 	Meets or Exceeds 	Need to 
Improve 	Meets or Exceeds 		
    Surgical Asepsis Principles & Practice 								
    Use and care of ultrasonic  instrument 
     cleaner 					NA	NA		
    Wrapping of instruments for sterilization 					NA	NA		
     Operation and care of heat sealer for 
     surgical instrument autoclave tape 					NA	NA		
     Operation and care of autoclave 					NA	NA		
     Proper opening of sterile packs 								
     								
    Immunizations 								
   Welcomes pt/family, establishes rapport,  and answers any questions								
   Explains what vaccines are to be given   								
Accommodates any language/literacy/special needs to help make them feel comfortable  								
 Completes & documents  screening questions    								
  Reviews comfort measures and after care instructions indicating correct dose of  Tylenol/Ibuprofen for weight  of ped pt   								
Identifies the location of emergency kit      								
 Identifies the location of the epinephrine, its administration technique and clinical situations where its use would be indicated    								
  Understands the need to report any needlestick injury and to maintain a sharps injury log   								
 Checks vial expiration date. Double-checks vial label and contents prior to drawing up    								
Maintains aseptic  technique throughout								
Selects the correct needle size. 
1-1 ½” for IM,  5/8” for SC 								
Mixes vaccine vial and/or reconstitutes and mixes using the diluent supplied. 								
Labels each filled syringe or uses labeled tray to keep them identified. 								
Demonstrates knowledge of proper vaccine handling ie: frozen vaccines Maintain cold chain								
Washes hands and puts on gloves prior to adminstration								
Demonstrates knowledge of the proper route for each vaccine    								
Area & Skill Set 	Self Assessment	Supervisor 	   Provider Reviews	Plan of Action	
	Need to 
Improve 	Meets or Exceeds 	Need to 
Improve 	Meets or Exceeds 	Need to 
Improve 	Meets or Exceeds 		
     Immunizations (Con’t) 								
  Positions patient and/or restrains the child with parent’s help   								
Demonstrates knowledge of the correct anatomical landmarks for injections     								
Preps the site with an alcohol wipe using a circular motion.  Allows to dry     								
Controls the limb with the non-dominant hand; holds the needle an inch from the skin and inserts it quickly at the appropriate angle (45 for SC or 90 for IM)								
Injects vaccine using steady pressure; withdraws needle at angle of insertion    								
Applies gentle pressure to injection site for several seconds with a dry cotton ball 								
 Properly activates the SafetyGlide needlestick protection    								
 Properly disposes of needle and syringe in sharps container.    								
 Properly disposes of used vaccine vials   								
Encourages comfort measures before, during and after the procedure								
Fully documents each immunization in the EMR (Date,  Type, Lot#, Manuf, site, VIS date,  exp date, name and initials)								
 Aks for and updates patient’s Imm Card    								
Knows  location and how to use the wall charts of the immunization schedules     								
Demonstrates knowledge of determining what immunizations are due at time of visit								

    								

								

								

	The Clinical Services Competency Checklist is a self-assessment tool for health care staff.  To complete it, review the competency areas and the clinical skills, techniques and procedures outlined for each of them.  Score yourself in the Self-Assessment column.  If you check Need to Improve you indicate further study, practice or training is needed.  When you check Meets or Exceeds you indicate you believe you are performing at the expected level of competence, or higher. 

Supervisors: Use the checklist to clarify responsibilities and expectations for staff that will be performing the skills.  When you use it for performance reviews, give staff the opportunity to score themselves in advance.  Next observe their performance as they provide the skill sets and score in the Supervisor columns.  If improvement is needed, meet with them to develop a Plan of Action that will help them achieve the level of competence you expect; circle desired actions or write in others.  In 30 days, observe their performance again.  When all competency areas meet expectations and meet Provider expectations, file the Competency Checklist in their personnel folder.  At the end of the probationary period and annually thereafter, observe them again and complete the Competency Checklist. 

Providers:  Use the checklist to document all skill sets you feel meet or exceed your expectations.  If there are any areas where improvement is needed, use the Competency Checklist to communicate with the staff’s supervisor to develop a Plan of Action for improvement.  Finally, all areas on the Competency Checklist will be signed off by the Provider indicating their agreement that their assigned staff performs the skills to meet or exceed their expectation. 

Plan of Action Legend:
1.	Watch video to review the techniques of the skill.
2.	Review manual, textbooks, wall charts or other printed guides.
3.	Search the internet for additional information 
4.	Observe other staff with patients.
5.	Be mentored by someone who has these skills
6.	Role play with other staff 
7.	Attend outside agency training, if available
8.	Attend cultural competency training 

Employee Signature:__________________________Time Period_____________________________

Supervisor Signature:__________________________Date:_______________________________

Provider Signature:____________________________Date:_______________________________