QMA Procedural Competency Checklist

Step 1 of 16

Employee Information

Employee Name(Required)

First Middle Last

Unit(s)(Required)

Harbor

Hearthside

Wellsprings

Horizons

Orientation

The following checklist will be completed within 90 days of start and then annually

Chemical Restraints/Sleep Inducing Medications

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Policy and Procedure(Required)

Satisfactory

Unsatisfactory

B. Various Forms(Required)

Satisfactory

Unsatisfactory

Code Procedure:

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Policy and Procedure for C.P.R.(Required)

Satisfactory

Unsatisfactory

B. How to identify Code Status for Resident(Required)

Satisfactory

Unsatisfactory

A. Emergency Cart(Required)

Satisfactory

Unsatisfactory

1. Location and survey of supplies available(Required)

Satisfactory

Unsatisfactory

2. Procedure for setting up the E-Cylinder(Required)

Satisfactory

Unsatisfactory

3. Use of A.E.D,(Required)

Satisfactory

Unsatisfactory

4. Assist nurse with appropriate documentation.(Required)

Satisfactory

Unsatisfactory

Condition Change/Reporting

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Reports changes in resident’s condition to nurse immediately.(Required)

Satisfactory

Unsatisfactory

B. Receives report from nurse and reports observations of residents throughout shift.(Required)

Satisfactory

Unsatisfactory

Daily Routine:

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Shift Report(Required)

Satisfactory

Unsatisfactory

B. Shift Rounds(Required)

Satisfactory

Unsatisfactory

Equipment

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

O. Glucometer (point of care testing procedure and disinfection of glucometer).(Required)

Satisfactory

Unsatisfactory

Infection Control

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Disposal of lancets device in sharps container(Required)

Satisfactory

Unsatisfactory

Point Click Care

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Policy and Procedure(Required)

Satisfactory

Unsatisfactory

B. Correct Procedure for using Point Click Care and Computerized Charting with Various Forms.(Required)

Satisfactory

Unsatisfactory

P.R.N. Medications

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Policy and procedure regarding Q.M.A. giving P.R.N. medications.(Required)

Satisfactory

Unsatisfactory

B. Q.M.A. is aware she must inform nurse and get her permission to give a P.R.N. medication.(Required)

Satisfactory

Unsatisfactory

Pharmacy:

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Policy and Procedure for Use(Required)

Satisfactory

Unsatisfactory

B. Administration Record (eMar)(Required)

Satisfactory

Unsatisfactory

C. Procedure for using(Required)

Satisfactory

Unsatisfactory

D. Medication Times(Required)

Satisfactory

Unsatisfactory

E. Treatment Record (eTar)(Required)

Satisfactory

Unsatisfactory

F. PCA Pharmacy Procedures(Required)

Satisfactory

Unsatisfactory

G. First Dose Machine policies and procedures(Required)

Satisfactory

Unsatisfactory

H. Emergency Drug List(Required)

Satisfactory

Unsatisfactory

I. List of Medications(Required)

Satisfactory

Unsatisfactory

J. Reordering / Returning Policy and Form(Required)

Satisfactory

Unsatisfactory

K. Pharmacy Books(Required)

Satisfactory

Unsatisfactory

J. Narcotic / Sign off Sheets(Required)

Satisfactory

Unsatisfactory

M. Charting Refusals(Required)

Satisfactory

Unsatisfactory

N. Destruction Procedures(Required)

Satisfactory

Unsatisfactory

O Medication discrepancy policy and forms.(Required)

Satisfactory

Unsatisfactory

P. Checking Deliveries(Required)

Satisfactory

Unsatisfactory

Q. Narcotic Storage / Count(Required)

Satisfactory

Unsatisfactory

R. Narcotic Book / Charting(Required)

Satisfactory

Unsatisfactory

S. Self-Administration(Required)

Satisfactory

Unsatisfactory

T. Adverse Drug Reaction (ADR) (identifies s/s and report to nurse immediately.(Required)

Satisfactory

Unsatisfactory

U. Informs nurse of discrepancies in drug: Inventories, documentation, and omissions.(Required)

Satisfactory

Unsatisfactory

V. Is able to list the 6 rights of medication administration.(Required)

Satisfactory

Unsatisfactory

W. Stays within time frame of medication administration.(Required)

Satisfactory

Unsatisfactory

X. Monitors for side effects of Psychotropic medications and reports signs/symptoms to the nurse.(Required)

Satisfactory

Unsatisfactory

Misc

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Assist with admissions and discharges under direction of nurse.(Required)

Satisfactory

Unsatisfactory

B. Obtains stock supplies for unit as needed.(Required)

Satisfactory

Unsatisfactory

C. Completes required medication inservices.(Required)

Satisfactory

Unsatisfactory

D. Maintains clinical competency in all areas of the C.N.A. responsibilities.(Required)

Satisfactory

Unsatisfactory

Respiratory Supplies

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Procedure for storage, delivery of and change out of oxygen tubing, masks etc…(Required)

Satisfactory

Unsatisfactory

B. Cleaning of equipment.(Required)

Satisfactory

Unsatisfactory

Other Competencies Based Upon Job Description

Satisfactory-shows competency with procedure and adequate knowledge of policy and procedure.

Unsatisfactory-does not show competency with procedure and adequate knowledge of policy and procedure, NEEDS REVIEW.

A. Policy and Procedures(Required)

Satisfactory

Unsatisfactory

B. General Job Duties(Required)

Satisfactory

Unsatisfactory

Comments

Comment

Procedural Competency Checklist Acknowledgement:

Acknowledgement(Required)

I acknowledged that I have performed the procedure as checked above and that I have a clear understanding of each procedure that was checked. I also acknowledge that this training has adequately prepared me for the assigned task.(Required)

QMA Signature(Required)

Date(Required)

MM slash DD slash YYYY

Name

This field is for validation purposes and should be left unchanged.