Up-Pgh Competency Program For New Employee

UP-PGH CBO
Table of Contents
INSTRUCTIONS FOR USE OF COMPETENCY BASED ORIENTATION PATHWAY (CBO)
DOCUMENTATION .2
WEEKLY OBJECTIVES 3
NURSING COMPETENCY BASED ORIENTATION PATHWAY13
GENERAL ASSESSMENT ....................................................................................... 13
NEUROLOGIC/BEHAVIORAL ................................................................................. 13
PULMONARY SYSTEM ............................................................................................ 15
CARDIOVASCULAR ................................................................................................. 18
GASTROINTESTINAL SYSTEM ............................................................................. 20
GENITO-URINARY SYSTEM .................................................................................. 23
ENDOCRINE & HEMATOLOGIC SYSTEMS ........................................................ 26
MUSCULOSKELETAL SYSTEM ............................................................................. 28
SKIN AND WOUND ................................................................................................... 32
PAIN/COMFORT ........................................................................................................ 35
SAFETY PRECAUTIONS ......................................................................................... 38
EMERGENCY RESPONSE ..................................................................................... 38
INTRAVENOUS THERAPY...................................................................................... 40
BLOOD ADMINISTRATION ..................................................................................... 41
AUTO TRANSFUSIONS ........................................................................................... 43
SPIRITUAL CARE/PSYCHOSOCIAL CARE ......................................................... 43
FOCUS AREAS .......................................................................................................... 44
RESTRAINTS AND SECLUSION ....................................................................... 44
COMMUNICATION ................................................................................................ 45
UNIT MANAGEMENT ........................................................................................... 46
PROFESSIONAL NURSE .................................................................................... 48
Page 1
UP-PGH CBO
Instructions for Use of Competency Based Orientation Pathway (CBO) Documentation
The purpose of this document is to assist the preceptor in providing a comprehensive and consistent orientation. It is intended to provide a foundation for practice
in the area of acute care to promote high standards of nursing practice.
It is the responsibility of individual acute care nurses to identify their practice parameters in accordance with Philippine nurse practice acts, professional codes,
professional practice standards, and their own competency.
The CBO guides the orientee in understanding the expectations of the University of the Philippines Philippine General Hospital Manila and documents the
orientation process received by new employees. It is intended to assist with the individualization of the orientation.
Responsibility of the Preceptor:

Obtains document from the preceptee
Reviews document as well as discuss learning needs of the new hire
Develops orientation plan in collaboration with the new hire to meet their learning needs and unit specific competencies
Explain competencies if learning option not available and where to find resources
Complete the CBO document by dating and initialing each statement, full signature at the end of the document
When orientation completed gives CBO document to nurse manager/ Assistant Nurse Manager
Responsibility of the Orientee:
Bring document to all clinical experiences
Review document and complete self assessment before unit based orientation begins
1 = no experience
2 = limited experience 3 = comfortable with experience
Collaborates with preceptor to develop individualized orientation
Remind preceptor to document completion of competencies as learning experiences occur
Recommend keeping CBO document on nursing unit
Communicate with preceptor frequently to ensure learning needs are met
Please Return this Document to the Nurse Manager when Completed.
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UP-PGH CBO
Weekly Objectives for New Graduate Registered Nurse (Goal: 1 12 weeks, variable)
WEEK
1
PRIMARY OBJECTIVE
Familiarize new employee with

Environment of Care and standards/
guidelines
(Limited patient care tasks)
PLAN
On Unit:
Day 1
1. No patient assignment for orientee or preceptor
2. Tour of hospital, including library as appropriate, nursing administration, conference rooms,
HR, other units, pharmacy, lab, radiology, operating room, Central supply, cafeteria
3. Preceptor review purpose and function of Competency Based Orientation (CBO) Pathway;
orientee complete self assessment
4. Orientee given unit-specific orientation protocols by preceptor
5. Meet with supervisory personnel and preceptor
a. Supervisory personnel, preceptor, and orientee review CBO self assessment
i. Identify clinical strengths and weaknesses of orientee
ii. Develop orientation plan
b. Align preceptor and orientee schedules
i. To accommodate no more then than two preceptors per orientee
ii. Coordinate Continuous Education and necessary classes; e.g. CVAD, EEG,
PTE, temporary pacemakers, et al.
iii. Identify off-unit learning opportunities; i.e. OR observation, Infusion Center,
Cath Lab, etc.
6. Unit tour including, but not limited to:
a. Medication room
i. Delivery of meds
ii. Distribution/ location of meds
iii. Methods of interface with pharmacy
iv. Proper medication labeling
v. Proper medication storage
vi. Proper medication handling
b. Physical structure of unit
i. # Beds and rooms
ii. Private vs semi private rooms (A&B)
iii. Locations:
1. Code blue button
2. crash cart
3. med room
4. nursing lounge
5. physicians lounge
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UP-PGH CBO
7.
8.
9.
10.
6. supply rooms
7. dirty utility room
8. nurses mailboxes
9. nurses station
c. Bed functions
i. Call lights
ii. Bed lights
iii. Positioning (trendelenberg, reverse trendelenbeg), degree of elevation
iv. Special bed indications and resources
d. Document storage (paper)
e. Patient medical record
f. Medication Administration Records (paper and electronic)
g. Nursing unit white boards
Safety procedures
a. Fire
b. Gas shut off valves
c. Evacuation route
d. Yellow name badge card
e. Codes
f. Evacuation devices
Administrative functions
a. Telephone etiquette
b. How to transfer a call
c. Red phones
d. Nondisclosure status
e. Work schedule: location and procedure
f. Process for vacation request, missed break or meal
Communication
a. Chain of Command
b. Paging protocol
c. Physician privileges
d. CPAR
e. Elements of Nursing Report
f. Who to Call/ MD coverage
g. Paging via WebRef
h. Primary vs consulting physician services
i. Physician ID numbers (PID)
j. UP-PGH phone book
i. Paper
ii. WebRef
iii. Blink
PCIS
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UP-PGH CBO
a. Printing of PCARS
b. Charting assessments
c. Charting Point of Care testing
d. Charting Care Plan
e. Charting PADB
f. Review report/results (lab, procedures, consults)
11. Resources
a. Nursing colleagues
i. Nurse Manager
ii. Assistant Nurse Manager
iii. Charge Nurse
iv. Preceptor
v. Interdisciplinary team
vi. Co-workers
vii. Superusers
viii. Nursing Education, Development, and Research
ix. Case Managers
x. Wound and ostomy nurses
xi. Vascular access nurses
b. Interdisciplinary colleagues
i. PT
ii. OT
iii. MD, NA, MW
iv. Nutrition
v. Speech
vi. RT
c. Pocket Reference Cards
i. Patient Safety Goals
ii. Phone numbers
iii. Core Values
iv. Pillars of Excellence
v. Clinical resources
d. Unit-specific resource binders
e. WebRef
i. MCPs (have new hire find blood administration MCP)
ii. Care Notes
iii. CP online
iv. Infection Control
v. Library
f. Lift team and/or lift devices
12. Equipment
a. Vital sign machines
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UP-PGH CBO
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
Sequential Compression Devices (SCDs)

Bladder scanner
Camera and printer
IV pumps
Vein finder ultrasound
Enteral feeding pumps
Patient transfer devices
Unit specific equipment
Overhead frame and trapeze
Skin cart- Hillcrest, Supplies- Thornton
Crash cart
Oxygen
i. Tanks
ii. Regulators
iii. Flow meters
n. Wall suction
o. Crash Cart
Day 2 Three patient preceptor/orientee assignment
1. Identify unit assignment board
a. Patient name
b. Nurse assignment
c. Physician
d. Fall precautions
e. Infection precautions
2. Participate in shift rounds if appropriate
3. Receive report per unit standard
4. Review medical record
5. Demonstrate ability to use paging system
6. Document in PCIS
Day 3 Three patient preceptor/orientee assignment
In addition to day two activities, recommend the following:
1. Obtain and give shift report
a. 3 day trend
b. Expectations for next shift
2. Participate in shift change routines
a. Walking rounds
b. Unit specific
c. Confirm Plan of Care with MD, HN, CN
3. Develop/ update plan of care with preceptor
4. If you havent already, introduce orientee to Educator
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UP-PGH CBO
Focus on acquisition of nursing skills and

basic patient care per CBO document
Week 2
through
4
Demonstrates increasing responsibility

and competence in providing total patient
care
At the end of each week, review progress
and establish goals for the next week.
Two patient assignment with direct preceptor oversight. May assist with admit or
discharge, transportation of patient, administer blood etc
1. Perform general assessment
2. Completes system focused assessment (neuro, CV, GI per patient diagnosis, needs
assessment as correlated with vital signs, I&O, labs, signs & symptoms)
3. Follow clinical pathways
4. Develop/ revise plan of care
5. Document with preceptor audit
A midpoint meeting should be scheduled at the end of week four.
Participants: 1) Nurse Manager, 2) Preceptor, 3) Educator, 4) Orientee
Focus: Review progress and accomplishments of the orientee toward orientation goals.
Bring to the meeting: 1) Nursing Competency Based Orientation Pathway and 2) Planning Guide
Objectives:
Review orientee strengths and accomplishments
Establish plan to support and encourage the orientee to achieve independent and
interdependent practitioner roles
Determine if orientation is meeting orientees needs
Realign orientation plan to meet orientees needs
Discuss orientees integration into unit culture
Insure that CBO document is up to date, identify elements for follow up on the CBO document
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UP-PGH CBO
Week 5
Identify patterns associated with common

illnesses on the unit. Trend changes in
patient assessment. Begin developing
formalized plan of care.
Two to three patient assignment in collaboration with preceptor.

1.
Develop system for prioritizing daily care

and managing the day.
3.
2.
4.
Continue with previous bedside objectives
and skill acquisition and expand per CBO
Pathway and as patient assignment
allows.
Week 6

Continue goals from week five, focus on
organization/ prioritizing/ achieving
autonomy.
allows.
Week 7
5.
Three to four patient assignment in collaboration with preceptor.

1.
2.
3.
4.

Continue with previous goals. Preceptor
assumes observer role (orientee
informing preceptor of plan of care).
Orientee demonstrating increased
autonomy.
5.
Proactively develop the plan of care for

assigned patients with minimal assistance
from preceptor.
3.
5.
Orientee to assume responsibility for a patient assignment with preceptor

observation.
1.
2.
4.
Page 8
UP-PGH CBO
allows.
Identify what duties can be appropriately
delegated to other members of the
healthcare team.
Week 8

allows.
Full assignment with backup by preceptor.

1.
2.
3.
4.
5.
Schedule a meeting at the end of week eight, including: 1) Nurse Manager, 2) Preceptor, 3)
Educator, 4) Orientee
Focus: Determine readiness of orientee. Identify orientees professional goals. Establish short
and long term plans. Introduce career choices.
Week 9
Bring to meeting: 1) Patient assessment, 2) plan of care, 3) vital signs, etc. for a full day of
patient care and the 4) CBO document.
Objectives:
Review orientee strengths and accomplishments
Establish plan to support and encourage the orientee to achieve independent and
interdependent practitioner roles
Determine if orientation is meeting orientees needs
Realign orientation plan to meet orientees needs
Discuss orientees integration into unit culture
Insure that CBO document is up to date, identify elements for follow up on the CBO
document
Evaluate documentation consistency within UP-PGH guidelines. If documentation issues
are identified, they will be shared with the orientee
Evaluate readiness to complete orientation, determine future planning
Develop mechanism for ongoing support, e.g. mentor, buddy
1.
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UP-PGH CBO
allows.
2.
3.
Refine practice to incorporate the Nursing

Process
Week 10

allows.
4.
5.
1.
2.
3.

Process.
Week 11

allows.
4.
5.
1.
2.
3.

Process.
Week 12

allows.
4.
5.
1.
2.
3.

Process.
4.
5.
Page 10
UP-PGH CBO
Weekly Objectives for Experienced Registered Nurse (Goal: 2 4 weeks orientation, variable)
WEEK
1
PRIMARY OBJECTIVE
Familiarize new employee with

Environment of Care and standards/
guidelines
(Limited patient care tasks)
PLAN
On Unit:
Day 1
No patient assignment for orientee the first 4 hours. Can be spent with preceptor or charge.
1. Complete CBO self assessment
2. Schedule weekly CBO Pathway progress meeting/ review reports
3. Tour of hospital
4. Scavenger hunt
5. Co-assignment with preceptor
a. Blood draws
6. Orientee to locate and review protocols for
a. Central line
b. Falls
c. Restraints
7. Patient co-assignment with preceptor for remaining 8 hours of shift.
a. Communication
i. CPAR
ii. Chain of command
Day 2
Full assignment between orientee and preceptor.
a. Expand skill acquisition including documentation per CBO Pathway and as patient
assignment allows
b. At the end of each day, review progress and establish goals for the next day
Day 3
Full assignment between orientee and preceptor.
a. Mid-day # 3, schedule time for weekly progress evaluation
b. Completion of CBO documentation
c. Proactively develop the plan of care for assigned patients with minimal assistance
from preceptor
Week 2 next page
Day 4, 5, 6
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UP-PGH CBO
Orientee takes full assignment with preceptor.
a. Preceptor oversight seeking out learning experiences, commensurate with
orientees assignment.
b. Identify what duties can be appropriately delegated to other members of the
healthcare team.
Mid-day, day 6
a. Weekly progress evaluation
b. Meet with Nurse Manager to make competency recommendation
c. Complete CBO Pathway documentation
3-4
Focus on acquisition of nursing skills and

basic patient care per CBO document
Week 3 4
Take full assignment.
a. Continue with previous bedside objectives and skill acquisition
b. Expand per CBO Pathway and as patient assignment allows
Meet with Nurse Manager, Educator to make competency recommendation, unit fitness
Page 12
UP-PGH CBO
UP-PGH NURSING Competency Based Orientation Pathway

Acute Care Nursing Units
Name:____________________________________ Annual Evaluation Date:________________
( )RN
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization
Codes for Self Assessment:

0 = No prior experience
1 = Limited experience
2=Performs independently
EVALUATOR
ASSESSMENT
Met
Date
Initials
GENERAL ASSESSMENT
Obtains head to toe assessment every shift (q12h)
and prn changes in patient condition or per MD order
Reviews history and physical, medical record, and
pertinent nursing documentation on admission
Assesses overall general appearance
Obtains, assesses and trends vital signs per routine,
prn changes in patient condition or per MD order
Assesses patient response to illness and treatment:
changes in body image, self concept, role
performance
Identifies problems from the assessment and
formulates a plan of care
Collaborates with patient/family to identify expected
outcomes
NEUROLOGIC/BEHAVIORAL
Assesses mental status, orientation using Glacow
Coma Scale (GCS)
Page 13
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Identifies abnormal findings:anxiety, agitation,

combativiness,seizures, CSF drainage, s/s of
increased ICP (blurred vision, slurred speech,
weakness, progressive sleepiness, vomiting,
worsening headache, unequal pupils, changes in
respiratory pattern)
Assesses patient for warning signs of stroke: sudden
onset of the following weakness, speech difficulty or
confusion, visual difficulty, dizziness, trouble walking
or loss of balance, severe headache with no known
cause
Verbalizes how and when to call a Stroke Code
Demonstrates computer resources and education
materials located on stroke center website
Inspects head and neck for sutures, dressings, drains
Assesses sensory impairments (visual,hearing, smell
and sensation)
Performs bedside water swallow screening test
Performs Interventions
Modifies nursing care related to sensory impairments
Teaches patient warning signs of stroke
Monitors and maintains dressings/drains
Documents assessment, problems & interventions
Identifies and describes seizure activity
Initiates and manitains spinal precautions as needed
Performs neuromuscular assessment
Page 14
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Performs focused neurological assessment in patient

with neurological deficits: pupil checks, motor strength
and sensory function, gait and balance
Intiates aspiration precautions as indicated
Collaborates with MD and speech pathology for
dysphasia evaluation
Follows spinal precautions (neuro/trauma/ ortho)
Verbalizes neurologic changes associated with aging:
decreased reaction time, decreased response to
painful stimuli, changes in speech and mobility,
changes in sense of smell, taste,sensation.
Verbalizes likelihood for intracranial bleed in geriatric
trauma victims
PULMONARY SYSTEM
Performs Assessment
Assesses patency of airway, rate, depth, pattern of

respirations, oxygen saturation, skin pallor, sputum
production
Auscultates breath sounds and identifies adventitious
breath sounds
Recognizes signs and symptoms of respiratory
distress or airway obstruction: tachypnea, use of
accessory muscles, increased respiratory effort on
inspiration, forced or protracted expiration, snoring,
crowing or stridor, asymmetrical chest movement,
cyanosis
Page 15
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Reassesses patient within 30 minutes after changes

in oxygen therapy or respiratory treatments
Assesses patient with chest tube for sub q
emphysema,dressing is dry, intact and occlusive.
Assesses chest tube/drainage device for patency,
integrity, water seal, tidaling, suction water levels,
amount, color & consistency of drainage, air leak,
device below level of chest tube, secured using nylon
bands; tubing is placed in a non dependent position
Evaluates effectiveness of oxygen therapy by
checking oxygen saturation, ABGs, and work of
breathing
Identifies and reports abnormalities: shallow irregular
breathing, hypo/hyper ventilation, dyspnea, apnea,
hemoptysis, SOB, use of accessory muscles and
abdominal breathing.
Initiates and maintains oxygen device: nasal cannula,
mask, non rebreather mask, oximizer, trach collar
Inserts oral or nasopharyngeal airways per patient
condition.
Obtains and verifies accuracy of pulse oximetry
values (pulse reading matches actual pulse)
Demonstrates use of bag valve mask
Positions patient to maximize oxygenation
Page 16
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Performs trach care every shift and prn: suctions

patient, inspects and cleanses skin surrounding
stoma, applies dressing and changes trach ties as
needed. Cleans or inserts new inner cannula every
24 hours.
Ensures tracheostomy equipment at bedside: suction
canister/set-up, suction catheters, replacement trach
of same size, obturator, disposable inner canula,ambu
bag,NS, oxygen regulator and delivery system
Ensures chest tube supplies are at bedside: sterile
water or NS, Vaseline gauze, 4X4's, clamp, tape
Obtains sputum specimen collection
Reviews diagnostics/labs, CXR, sputum, ABG, PFT,
culture and sensitivity, angiogram/VQ scan
Describes safety measures when transporting a
patient with a chest tube: verifies with MD if okay to
be off suction, removes suction port tubing and does
not cover or clamp any tubing, and ensures chest
drainage device below level of chest tube insertion
Demonstrates chest tube drainage device set up and
replacement
Collaborates with Respiratory Therapy (RT) for
changes in patient's respiratory effort, BiPAP needs
Assess patient's response to BiPAP therapy and
maintains BiPAP supportive therapy(effective seal,
skin integrity, comfort, calming measures)
Page 17
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Demonstrates effective airway management: opens

airway and removes secretion &/or foreign bodies
Educates and encourages patient to use secretion
mobilization devices: incentive spirometer, PEP, and
flutter device
Documents assessment, problems and iinterventions
CARDIOVASCULAR
Performs Assessment
Auscultates heart sounds (S1,S2), apical pulse
Identifies & reports abnormalities: chest pain, hypohypertension, tachycardia > 100 beats /min,
bradycardia < 60 beats/min, irregular heart rate.
Absent, weak, bounding or thready pulse. Pale,
cyanotic or mottled skin color.Capillary refill > 3
seconds, edema, shortness of breath, jugular venous
disention.
Assesses vital signs and oxygen saturation.
Palpates peripheral pulses for rhythm, amplitude and
bilateral equality
Assesses peripheral pulses using a Doppler
Assesses peripheral perfusion e.g. skin temp,
color,capillary refill
Assesses fluid volume status ( excess versus deficit),
daily weight, edema,s/s CHF.
Assesses AV fistula and/or AV graft for bruit, thrill,
pulse, and condition of dressing or drainage if present
Page 18
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Monitors cardiac rhythm and analyzes and interprets

the following rhythms; normal sinus rhythm,
tachycardia, bradycardia, PAC, PVC, atrial
fibrillation/flutter, ventricular tachycardia/fibrillation
Verbalizes cardiovacular changes associated with
aging: irregular apical pulse, murmurs, ECG
abnormalities, hypertension, orthostatic/postural
hypotension
Verifies vital signs prior to administering cardiovacular
medications
Reviews parameters for medication administration
(PCAR/MAR, patient condition)
Administers and evaluates patient's response to
medications including but not limited to: diuretics,
digoxin, antihypertensives, dysrhythmics and antithrombotics.
Applies and maintains anti-embolism stockings/
sequential compression devices. Identifies time off is
limited to 1 hour every 12 hours.
Reviews chest x-ray report and verifies MD
awareness of results if abnormal
Reviews labs/ diagnostics: troponin, CK, CKMB,
cardiovascular drug levels, Hgb, Hct, basic metabolic
panel, lipid panel, ECG, echocardiogram, stress test
and/ or nuclear medicine scans
Positions patient for comfort and optimal circulation
Page 19
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Documents patient's tolerance in performing ADL's

Assesses for patient smoking cessation needs; offers
cessation program information
Assesses appropriate diet, medication, life style
choices.
Completes and documents acute MI and Heart Failure
Core Measures
Educates, teaches and completes discharge
information specific to cardiovascular disease.
Provides education booklet re: heart disease.
Informs MD of rhythm abnormalities, abnormal labs,
hemodynamic changes; and telemetry changes
Connects epicardial/transvenous wires to pacemaker
and presses emergency button as indicated. Applies
transcutaneous pads and connects to pacemaker
module, turns device on, sets rate to 60 and MA at 20
Documents patient's tolerance of performing ADL's
Documents rhythm when obtaining a set of vital signs
GASTROINTESTINAL SYSTEM
Performs Assessment
Inspects, auscultates, and palpates the abdomen
Assesses oral cavity
Page 20
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Assesses nutritional status; labs, intake, calorie count,

weight, swallowing impairment, food preferences
Evaluates nutritional and fluid intake. Collaborates
with nutrition services when indicated.
Assesses all GI drains/ tubes; patency, output, color,
consistency & amount of drainage
Assesses enteral feeding devices and site
Identifies abnormalities: oral mucosa, infections of the
mucosa, altered bowel sounds, muscle wasting,
abdominal pain, jaundice, changes in bowel habits,
constipation , diarrhea, stenorrhea, nausea, vomiting,
hemoptysis, hematemesis, evidence of dysphasia or
aspiration
Assesses presence of ostomy: output, stoma viability,
skin condition
Verifies and documents daily bowel movement
Evaluates geriatric age related changes: Increased
gastric emptying time, decreased salivary flow,
decreased absorption, decreased gastric acid
secretion, reduced gastrointestinal motility resulting in
alteration in drug metabolism and bowel habits.
Evaluates fluid & electrolyte status related to nausea,
vomiting, & diarrhea and implements treatment
regimen
Evaluates lab results: albumin, pre-albumin, total
lymphocyte count
Verifies initial placement of small bore feeding tube by
x-ray report. Marks and documents tube length at
Page 21
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
nare.
Ongoing assessment for nasal feeding tubes: verifies
that marking is at nare, tube is not coiled at back of
throat.
Assesses for watery eyes, coughing and changes in
vocal quality which indicates incorrect tube placement
Inserts and maintains nasogastric tube for suctioning
and/or small bore feeding tubes for nutrition
Maintains patency of feeding tubes. Flushes with NS
q 4-6 hr, & before and after medications
Uses aseptic technique when handling enteral
feeding: washes hands, dons non sterile gloves when
setting up tube feeding, administering meds, checking
residual.Uses med administration port when giving
meds or checking residual.
Administers medications via a gastric or nasogastric
tube
Confirms placement of nasogastric tube by
auscultation of injected air and aspiration of stomach
contents (if able).
Administers medications to alleviate constipation and/
or diarrhea
Collaborates with MD and institutes a bowel
management program
Page 22
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Date
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UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Enter Name of
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Manager for
follow up
METHOD
RESOURCES
Initials
Prepares patients for GI diagnostic testing

Collaborates with MD for stress ulcer prevention
Trends and evaluates weight changes
Acute Care
Guidelines of
Care
Monitors NPO status and collaborates with MD and

nutrition to ensure adequate nutritional intake
GENITO-URINARY SYSTEM
Performs Assessment
Reviews patient history for renal insuficiency, renal
failure, renal transplant
Inspects perineal area and assesses mucous
membranes
Page 23
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Date
Performs administration of enema, suppositories
Documents amount of food ingested by number of

items eaten (1-5)
Documents intake and output
Ensures oral care for patient's with stomatitis, herpes
simplex of mouth is provided, NPO or ADL dependent
Maintains apiration precautions: HOB elevated 30
degrees, suction at bedside, proper placement of
cervical collar , high semi-fowler's for 30 mnutes after
eating
Collaborates with pharmacy to identify medications
that cause or relieve nausea or anorexia
FOLLOW UP
EVALUATOR'S
INITIALS
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Reviews patient's record to determine clinical

conditions that may effect fluid status; e.g. ESRD,
renal insuficiency, CHF, dehydration
Performs bladder volume assessment using the
bladder scanner
Monitors intake and output
Assesses urinary devices for patency, amount, color
& clarity of drainage
Assesses for bladder spasms/discomfort and
implements treatment
Obtains and labels lab specimens as ordered or
indicated for patient's condition
Assesses perineum
Collaborates with MD to ensure optimal fluid
management
Secures urological tubing with securement device
Obtains & labels specimen from catheter
Demonstrates irrigation of urological catheters; e.g.
manual, IBI, CBI (use of sterile irrigant and
equipment)
Evaluates urinary output (color, quantity, clarity, odor,
etc).
Evaluates for changes in urinary patterns (frequency,
urgency, pain, burning )
Obtains and labels 24 hour urine collection sample
Page 24
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FOLLOW UP
FOR "DOES
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Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Verbalizes that NO blood pressure readings, lab

draws or IV starts are done in extremities with
hemodialysis access or anticipated hemodialysis
access
Identifies adverse effects of hemodialysis: bleeding,
hypotension and hyperglycemia
Administers pain, insulin, anticonvulsant medications
irrespective of hemodialysis; consults with MD to hold
all other medication categories
Verbalizes abnormal findings: pain, dysuria,
increased urinary frequency, anuria, oliguria, polyuria,
distention, blood, sediment, odor of urine, flank
tenderness or bruising, edema, evidence of
hemodialysis or peritoneal dialysis.
Reviews labs/ diagnostics results: UA, phosphate,
hemogram, BMP panel, culture and sensitivity, 24 hr.
urine, IVP, ultrasound of kidneys, angiogram, KUB
Inserts foley & maintains urinary drainage devices
Inserts a urinary catheter in males so that the hub is
all the way to the tip of the penis. Observes for urine,
then inflates balloon with sterile water (not normal
saline).
Verbalizes technique for removing a difficult Foley
catheter; if unable to deflate balloon instills 2 - 3 mls
of sterile water in balloon port then aspirates the water
and then gently removes the catheter.
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Recommends urological consultation when catheter

insertion or removal is difficult
Verbalizes genitourinary changes associated with
aging : altered patterns of urinary elimination, volume
changes/shifts, increased creatinine clearance,
increased risk for urinary incontinence, UTI,
urosepsis, and BPH.
Educates patient about care of catheter and drainage
devices
Documents assessment, problems & interventions.
Documents any changes in urinary status since
admission
Documents intake and output
Documents amount, clarity and color of urine and
uses fruit juices to describe color
Documents outcome of bladder scan
Communicates changes in patient's urinary status to
physician
ENDOCRINE & HEMATOLOGIC SYSTEMS
Performs Assessment
Reviews history and physical for endocrine and
hematological disorders, specific drug therapies e.g.
1) hormone replacement, 2) thyroid, 3) corticosteroids
Assesses functional status: activity tolerance, selfcare deficit, fluid volume excess, low BP, constipation;
weak, lethargic, temperature intolerance, skin
changes, weight gain, mental status, slowed/ slurred
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Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
speech, moon-face
Reviews laboratory values: hypo-hyperglycemia,

131
HbA1c, thyroid function (TSH, T3, T4, I ), adrenal
function (cortisol)
Assesses patient's knowledge and understanding of
diabetes, thyroid disease, Cushingss
Weighs patient upon admission or as ordered/
indicated
Performs bedside glucose measurement
Trends glucose readings
Collaborates with physician to achieve optimum
glycemic control
Evaluates patient for signs and symptoms of hypohyperglycemia
Initiates dietitian consultation
Assesses need for laboratory testing, collaborates
with MD on use of hematopoietic growth factors
Initiates hypoglycemia protocol when indicated.
Verbalizes location of hypoglycemia protocol.
Educates patient with focus on knowledge deficits
identified in the diabetes assessment form.
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Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Documents glucose readings, episodes of

hypoglycemia and treatment and patient's response
Documents diabetes education
Documents that the diabetes education booklet was
provided and written information was given to the
patient.
Documents the titles/names of written information
given to patient in the plan of care
Documents pt/family understanding of diabetes
education
Maintains appropriate temperature comfort measures
(blankets, circulation)
Tracks signs & symptoms of thyroid over-medication
(tachycardia, nervousness, insomnia)
MUSCULOSKELETAL SYSTEM
Performs Assessment
Reviews H & P, operative report, trauma report
Performs pain assessment
Inspects musculoskeletal system: spinal alignment,
gait, extremities, strength
Compares affected to unaffected side/extremity
Identifies abnormalities: spinal curvatures, kyphosis,
loss of height, asymmetry, dislocations, contractures,
stiffness or fixation of joint, deformity, evidence of
fracture or dislocation, tenderness, warmth, coolness,
moistness, skin changes, bone or joint crepitus,
numbness and tingling.
Page 28
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FOLLOW UP
FOR "DOES
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Identifies abnormal findings: numbness, parasthesia,

flaccidity, lack of muscle movement, weak, thready, or
bounding pulses, compartment syndrome
Assesses affected areas for variation in skin color,
skin temperature, skin turgor, nodules, masses,
swelling, hematoma
Assesses body position, mobility & muscle strength
Assesses pulses, capillary refill, movement and
sensation of affected extremities
Assesses orthopedic appliances for proper
application, including but not limited to: traction, Halo,
external fixator, continuous passive motion, cast,
sling, splint
Assesses for complications related to ortho devices
(e.g. skin breakdown, increase in pain, improper
placement), loosening of screws, pins
Evaluates range of motion. .
Assesses patients admitted with orthopaedic devices:
e.g. external fixators, halo, casts, braces, slings
Assesses neuromuscular and neurovascular status of
affected area. Compares to unaffected side.
Performed together by the off-going & on-coming RN.
Evaluates labs/diagnostics: CBC, calcium,
phosphorus, sedimentation rate (ESR), rheumatoid
factor (RF), C-reactive protein (CRP), x-rays, bone
scans, MRI, Mylogram, CT scan, EMG, culture &
sensitivity, SGOT, uric acid, PT, PTT, INR
Maintains total hip, knee, spine and fall precautions
Page 29
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FOLLOW UP
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Assesses use of and/or need for assistive device

Verbalizes musculoskeletal changes associated with
aging: loss of muscle and bone, decreased muscle
strength, frail bones, decreased coordination, gait
changes, increased muscle fatigue, kyphosis
Identifies needs of patients with spinal cord injury,
amputation, quadraplegia, hemiplegia, and/or
paraplegia
Performs secondary post trauma assessment
Assesses bowel/bladder patterns and identifies
abnormalities
Assesses proper assembly of overhead frame and
trapeze
Notifies MD of alteration in motor function or
sensation of extremities
Applies & maintains orthopaedic devices: braces,
kydex jacket, CPM, knee immobilizer, slings,
prostheses and/ or orthotics, post operative shoes
Utilizes appropriate assistive devices
Collaborates with OT, PT, Ortho Technician
Utilizes joint arthroplastic clinical pathways
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FOLLOW UP
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Educates patient and family on signs and symptoms

of common complications associated with
musculoskeletal injury: surgical site and bone
infection, hemorrhage, VTE (PE, DVT), compartment
syndrome, neurovascular compromise, fat emboli,
dressing /cast constriction, immobility
Reinforce safety measures related to ADL's
secondary to changes in center of gravity
Evaluates sensory/motor effects of regional nerve
block
Ensures antibiotics are administered in accordance
with Surgical Infection Prevention Guidelines
Applies elevation and ice as indicated
Maintains traction
Collaborates with case manager & social worker to
assist with discharge needs
Performs pin site care
Provides VTE prophylaxis: pharmacologic, sequential
compression devices, ankle pumps
Assesses and communicates lab results to MD
Follows spine precautions (cervical collar per MD
orders, full log role, order specialty bed, used
slideboard)
Documentation
Documents assessment of abnormal findings,
problems & interventions. Recognizes critical changes
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Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
and contacts MD
Documents appliances, devices, mobility status
Documents skin integrity
Documents neuromuscular and vascular status
Documents and trends labs (Hgb and Hct, PT, PTT,
INR) Documents reporting abnormalities to MD
Documents nutritional intake and output
Documents patient's adherence to mobility restrictions
Documents non pharmacological interventions for
comfort
Documents patients mood
SKIN AND WOUND
Performs Assessment
Assesses skin for intactness, integrity, moisture,
dryness, edema
Assesses need for specialty bed
Inspects hair, nails, and skin for cleanliness
Determines pressure ulcer risk using Braden Scale on
admission, every shift and changes in patient
condition
Assesses skin closures for sutures, staples, and other
skin closures
Assesses intactness and appropriateness of dressing
and drainage q shift, prn and changes in patient
condition
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FOLLOW UP
FOR "DOES
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
Initials
Assesses bony prominences

Verbalizes skin changes associated with aging:
decreased moisture, elasticity, friability, mobility,
sensation. Inventories factors associated with skin
breakdown; e.g. chronic illness, medications
Identifies abnormalities: rash, itching, lesions,
masses, wounds and surrounding tissue, pressure
ulcers, break in skin integrity, stoma,drainage,
hematoma, ecchymosis, infections, pain, tightness,
non healing wounds, dehiscence, evisceration
Initiates skin care protocols
Documents wounds including staging, length, width,
depth, appearance, drainage, presence of slough or
necrosis, type of dressing
Photographs wounds upon admission, weekly,
discharge and changes in wound condition
9
9
Participates in wound and skin surveys
Page 33
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Date
Assesses and reassesses character of wounds with

each dressing change. Not to exceed 7 days
Initiates consultation to Surgical wound team for

unresolved skin issues
Encourages and provides daily hygiene
Collaborates with MD for podiatry referral
Applies and maintains dressings as indicated
Removes any dressing from another institution upon
admission and evaluates wound
FOLLOW UP
EVALUATOR'S
INITIALS
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Educates patient and family regarding wound, wound

care and methods to relieve pressure and enhance
adequate circulation
Verbalizes indications and maintainence of wound vac
Collaborates with Wound Ostomy Continence Doctor
for stage 3 and stage 4 wounds (full thickness
wounds)
Provides the following measures to prevent skin
breakdown: turn q 2hrs, pads bony prominences, use
of pillows, raises heels off bed, moisturizes dry skin,
cleans incontinence as soon as possible
Collaborates MD for application of pressure
reducing/relieving devices for beds and chairs
Encourages and promotes optimal nutritional intake.
Considers nutrition consult
Sets up lifting devices: trapeze, overbed frames
Implements use of lift team when applicable
Obtains and labels wound culture
Documents wound status, changes in condition
Documents use of special mattress
Documents turning schedule
Documents dressing change: time, date, size, odor,
drainage, treatment
Documents stoma color, moisture, position and
drainage
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FOLLOW UP
FOR "DOES
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Documents wound culture obtained

Documents education to patient and family for optimal
skin care and prevention of skin breakdown
PAIN/COMFORT
Performs Assessment
Assesses patient's pain using hospital approved
scales on admission, at beginnning of every shift, with
each set of routine vital signs and with any
procedures or activity in which pain may be
anticipated and/or every 4 hours
Assesses pain related to intensity, location, quality,
pattern, onset/duration, intervention and effect of
intervention
Reassesses patients comfort level if pain score is
equal to or greater than 4, 1 hour after IM/IV
medications, 2hr after oral medications until pain
controlled and with each set of routine vital signs
Reviews medical record for type of surgery or
procedure, disease states associated with moderate
to severe pain e.g. sickle cell crisis,
immunosupression (HIV, diabetes, cancer), joint
disease, shingles, as well as anesthetic or analgesic
medications administered
Asks patient to determine acceptable level of
pain/individual pain goal on initial screening and PRN
Obtains patient's analgesic history including opioids,
non-opioids, and adjuvant analgesics, e.g. anticonvulsants, anti-depressants
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Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
Initials
The Nursing
Practice Act
Section 2725
(B)(1)
Monitors patient's response to pain medications:

relief or reduction in pain as well as adverse effects of
medications (e.g. hypotension, hypoventilation,
itching, N/V, constipation and altered mental status,
Collaborates with MD to ensure timing of pain
management regime. Addresses need to change
medication schedule if periods of uncontrolled pain
exist
Page 36
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Date
Obtains patient's history of non-drug pain therapies

Identifies abnormal findings associated with
unrelieved pain: increased BP, HR, RR, behavioral
changes, diaphoresis, grimacing, guarding,
hypoventilation, abdominal rigidity, atelectasis,
fatigue, sleep deprivation
Validates patient's advocate/family report of pain
Differentiates between patient's pain, anxiety,
confusion, delirium and identifies when to use the
RASS scale (+4 to 0 to -5)
Verbalizes pain issues related to aging: concept of
pain, reporting pain, altered ADLs, depression
Assesses chronic pain management and
effectiveness
Administers pain/comfort medications based on
patient's self-report/nonverbal behaviors and nurses
assessment of patient's physiological status (e.g. BP,
RR, O2 sat)
FOLLOW UP
EVALUATOR'S
INITIALS
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Implements non-pharmacological measures for

treatment of pain/discomfort; e.g. elevation, ice,
positioning, massage, distraction therapy
Advocates for adjunctive holistic therapies when
requested by the pt/family
Performs set up of pain management devices
(parenteral or epidural) and attaches to patient
Teaches patient how to use pain management
devices. Reminds family/friends to not activate pain
management device
Trends patients response to and satisfaction with pain
management
Monitors regional nerve block devices for patency,
leakage, dislodgement, and effectiveness
Verbalizes /demonstrates how to deliver a bolus of
medication through epidural and PCA catheters
Collaborates with primary MD for referral to Pain
Management Service
Ensures all epidural tubing is labeled with epidural
signs
Demonstrates use of non verbal pain scale to rate non
verbal patient's pain
DOCUMENTATION
Documents assessments, problems, and interventions
on designated pain management record
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Documents comprehensive pain management history

on PADB (Patient Admission Database)
Documents pain rating and in the pain
assessment/reassessment screen
Initiates pain as a problem in the plan of care
Utilizes the elements of informed consent
SAFETY PRECAUTIONS
Verbalizes isolation precautions; AFB airborne,
airborne, droplet, contact and neutropenic
Aspiration, bleeding, falls, infection, neutropenia,
restraints, seizure precautions, disaster preparedness
Provides safe environment: side rails up, call bell
within reach, bed in low position, room clear of clutter,
sufficient lighting
Lists or knows where to find safety goals
EMERGENCY RESPONSE
Performs Assessment
Describes and Initiates emergency code response
Implements cardiopulmonary resuscitation, when
indicated
Assesses status of Advanced Directive content
Assesses for DNR order
Documents Assessment, Problems and Interventions
Patient Education
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Enter Name of
Supervisor/
Manager for
follow up
METHOD
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Initials
MCP 380
Checks resources for identified drug allergies

Instills eye lubricants and drops
Assesses need for & response to PRN meds
MCP 380.1
MCP 305.1
MCP 380.1
Verbalizes the 5 Rights of medication administration
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Assesses learning needs and barriers

Performs periodic reassessment of needs
Identifies best method of learning for pt/family
Performs Educational Interventions
Reviews discharge instructions with patient and/or
responsible adult
Educates patient/family of treatments or devices
requiring home care upon discharge / e.g. injections,
assistive devices, drains, dressings, irrigation
catheters, etc.
Ensures return demonstration of teaching
Provides printed discharge instructions to patient
Ensures patient or responsible adult signs discharge
instructions
DOCUMENTATION
Medication Management
Performs Assessment
Assesses patient for possible contraindications of
medications prescribed
FOLLOW UP
EVALUATOR'S
INITIALS
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Follows hospital guidelines for administration of highrisk medications

Maintains medication areas neat and free of
clutter/trash
Verbalizes multi dose vial policy and labels multi-dose
vial with expiration date
Obtains access to Pyxis. Removes medications from
Pyxis
Logs into Pyxis device and obtains medications, exits
after use
Verbalizes definition of Adverse Drug Reaction
Initiates and or edits the Medication Reconciliation
form
Collaborates with MD and/or pharmacist to ensure
continuity of medication regimen
Reviews Medication Reconciliation form on discharge
for accuracy and educates patients on medication
regime to continue upon discharge
Assesses patient response to medication and
intervenes if indicated
Documents all medications administered
Intravenous Therapy
Performs Assessment
Verbalizes changing field IV access site within 24
hours of admission to the hospital if patient a trauma
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Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
victim
Selects IV catheter size according to patient need
Assesses for presence of central and peripheral
venous access; identifies infiltration, occlusion and
dislodgement of catheters
Performs venipuncture according to policy
Maintains & changes dressings per standards
Maintains & utilizes saline locks according to
standards
Utilizes non free-flow devices with all infusion pumps.
Demonstrates free-flow check.
Utilizes/maintains pumps per manufacturer guideline
States/demonstrates proper procedure for D/C IV
BLOOD ADMINISTRATION
Assessments
Verifies MD order for transfusion of blood product,
differentiates that an order for a type and cross match
is not an order to transfuse
Verbalizes indication for transfusion
Verifies consent for blood transfusion is present in
chart, if not notifies MD
Verbalizes that each blood administration tubing is
good for 4 hours or 2 units of blood products
whichever occurs first
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Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Assesses that IV access for patency and that needle

gauge is 22 g or larger
Verbalizes that all blood products (except Clotting
Factors 8, 9 and Rhogam) require a blood filter
Verifies with second licensed person the transfusion
order. Verifies the blood bag matches the transfusion
record. This includes 1.) donor and recipient ABO
type, 2.) expiration date, and 3.) blood unit number
Verifies at the bedside the patient's name and ID on
the patient's armband matches with the transfusion
record.
Documents with 2 signatures on the transfusion
record
Verbalizes signs and symptoms of transfusion
reaction
Verbalizes actions to be taken in the event of a
transfusion reaction
Verbalizes that IV pump may be used for blood
administration.
Returns blood /blood product to Blood Bank if not
used within 30 minutes of removal from Blood Bank
Completes Blood Product Pick -Up form, pick up
blood product from Blood Bank
Verifies baseline vital signs were obtained within 30
minutes before the start of transfusion
Page 42
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METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Enter Name of
Supervisor/
Manager for
follow up
METHOD
RESOURCES
Initials
Completes infusion of blood within 4 hours of removal

from blood bank
AUTO TRANSFUSIONS
Assessment
Verbalizes use of micro-aggregate filter in addition to
filter in standard blood administration set
Completes infusion of salvaged (shed) blood within 8
hours of drain insertion
MCP 617.1
Page 43
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Obtains vital signs 15 minutes after start of infusion

and observes pt. closely. May delegate remainder of
vital signs every hour until transfusion completed
Verifies baseline vital signs were obtained within 30

minutes of start of transfusion
Obtains vital signs 15 minutes after start of infusion
and observes pt. closely. May delegate remainder of
vital signs every hour until transfusion completed or
discontinued
Documents vital signs, amount of blood product
infused and if a patient has had a transfusion reaction
on the transfusion record
Spiritual Care/Psychosocial Care
Performs Assessment
Assesses spiritual perspective of health
Assesses spiritual needs during treatment
FOLLOW UP
EVALUATOR'S
INITIALS
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Verbalizes indications for contacting Social Work and
Pastoral Care
Demonstrates ability to access Social Work and
Pastoral Care
Provides means to meet spiritual needs
Considers spiritual needs when providing care
Addresses spiritual needs in Plan of Care
Advocates for patient's requests for
chaplaincy/spiritual counsel
Focus Areas
Restraints and Seclusion
Performs Assessment
Initiates alternative measures to use of restraints: e.g.
de-escalating behavior, moving bed closer to nurses
station, family members at bedside, judicious use of
medications, distraction techniques
Identifies patients at risk for needing restraint
Differentiates between the need for medical vs.
behavioral restraint
Applies and maintains restraints, obtains MD order
within 12 hours of applying restraint
Reassesses need for continuing restraints every 2
hours
Properly applies restraints
Monitors restrained patient at required time intervals
Documents Assessment, Problems &
Page 44
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Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Interventions
Checks presence and timeliness of MD order and
renewal order
Completes restraint seclusion documentation form
frequency?
Appropriately enters patient data in Unit log book
COMMUNICATION
Communicates clearly and concisely
Gives change of shift /hand off report that includes
patient age, dx, problems, plan of care treatments,
interventions, response to care and progress in
attaining goals
Prioritizes care using critical thinking, trending of vital
signs, data, monitoring, timeline strategies and
specified goals. Evaluates and communicates results.
Demonstrates paging system including phone page,
emergency page.
Delegates tasks and assignments appropriately to
members of the team to include: NA, INTERNS, RN,
other clinical staff
Makes shift change rounds with on-coming RN
Verbalizes how and when to obtain intepreter
services: must be used for consent, relaying of
diagnoses and assessment
Identifies needs of diverse populations, cultures and
custodial patients
Page 45
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METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Recognizes and communicates an appropriate plan

for dealing with an ethical dilemma; requests an ethics
consultation
Communicates risk management issues by
communicating with charge nurse, nurse manager
and completing of QVR (Quality Variance Report)
Contacts security to assist with management of
aggressive, combative, attempting to elope or sign out
patients
Unit Management
Performs tour of nursing units, nutrition services,
discharge pharmacy, inpatient pharmacy, cafeteria,
conference rooms, Interventional Radiology, Lab, and
Radiology
Reviews location and contents of: mailboxes,
resource manuals (unit, equipment and competency),
intranet, MCPs, patient refreshments, patient
education materials
Uses hospital operator to determine physician on call
or uses scheduling in web reference to locate on call
physicians
Locates and reviews work schedule
Locates and documents on appropriate schedule
forms the following: requesting specific schedule,
vacation time, education leave, floating holidays
Uses ATM system for payroll
Locates fire alarms and verbalizes use
Locates fire extinguisher and demonstrates use if
Page 46
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Supervisor/
Manager for
follow up
METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
EVALUATOR
ASSESSMENT
Met
Date
Initials
trained
Locates oxygen shut off valve and verbalizes how to
shut off if instructed to do so
Locates emergency exits and reviews emergency
evacuation routes
INTERVENTION
Activates code system and demonstrates use of code
alerts:
ADAM
= abducted or missing infant/child
BLUE
= medical emergency response
ORANGE
= internal hospital emergency
PINK
= maternal/child emergency
RED
= fire response
TEN
= bomb threat
GREY
= disruptive or violent behavior
TRIAGE
= mass casualty STROKE CODE=new
onset stroke symptoms
TAN
= Bomb Threat
GREY
TRIAGE
STROKE
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

= Disruptive Behavior
= Mass casualty
= New onset of stroke symptoms
Accesses Web-Outlook once a shift and PRN

Accesses web reference for clinical guidelines,
micromedex, care notes, policies and procedures,
physician schedules
INTERVENTIONS
Page 47
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Manager for
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METHOD
RESOURCES
FOLLOW UP
EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
Code for Method

O = Observation
S = Simulation/Demo
CR = Chart Review
V = Verbalization

EVALUATOR
ASSESSMENT
Met
Date
Initials
Verbalizes and demonstrates use and problem

solving of the following equipment: beds, gurneys,
monitors (set-up, alarm settings, pressure lines), IV
pumps, PCA device, epidural/regional device,
sequential compression devices, auto-transfusion
devices Is there a checkoff for this??
PROFESSIONAL NURSE
Informs patient of rights and responsibilities
Advocates for pt./family by 1.) Assisting them to
define needs and establish goals 2.) Participates in
decision making 3.) Provides care congruent with
pt./family needs/goals 4.) Upholds pt./family rights 5.)
Demonstrates cultural competency
Maintains professional appearance
Wears name badge while on duty with photo clearly
visible
Demonstrates an attitude of respect for patients,
visitors and employees
Signatures: include initials with full signature &
title. example: JSD- Juan S. David, RN
Orientee
Preceptor 1
Preceptor 2
Page 48
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METHOD
RESOURCES
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EVALUATOR'S
INITIALS
FOLLOW UP
FOR "DOES
NOT MEET"
ASSESSMENT
Date
Initials
Page 49

Up-Pgh Competency Program For New Employee

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Up-Pgh Competency Program For New Employee

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UP-PGH CBO

Responsibility of the Preceptor:

Please Return this Document to the Nurse Manager when Completed.

Familiarize new employee with

Sequential Compression Devices (SCDs)

Focus on acquisition of nursing skills and

Demonstrates increasing responsibility

Identify patterns associated with common

Two to three patient assignment in collaboration with preceptor.

Develop system for prioritizing daily care

At the end of each week, review progress

Three to four patient assignment in collaboration with preceptor.

At the end of each week, review progress

Proactively develop the plan of care for

Continue with previous bedside objectives

Orientee to assume responsibility for a patient assignment with preceptor

At the end of each week, review progress

Full assignment with backup by preceptor.

Continue with previous bedside objectives

Refine practice to incorporate the Nursing

At the end of each week, review progress

Refine practice to incorporate the Nursing

At the end of each week, review progress

Refine practice to incorporate the Nursing

At the end of each week, review progress

Refine practice to incorporate the Nursing

Familiarize new employee with

Focus on acquisition of nursing skills and

UP-PGH NURSING Competency Based Orientation Pathway

Code for Method

Codes for Self Assessment:

Code for Method

Codes for Self Assessment:

Identifies abnormal findings:anxiety, agitation,

Code for Method

Codes for Self Assessment:

Performs focused neurological assessment in patient

Assesses patency of airway, rate, depth, pattern of

Code for Method

Codes for Self Assessment:

Reassesses patient within 30 minutes after changes

Code for Method

Codes for Self Assessment:

Performs trach care every shift and prn: suctions

Code for Method

Codes for Self Assessment:

Demonstrates effective airway management: opens

Code for Method

Codes for Self Assessment:

Monitors cardiac rhythm and analyzes and interprets

Code for Method

Codes for Self Assessment:

Documents patient's tolerance in performing ADL's

Code for Method

Codes for Self Assessment:

Assesses nutritional status; labs, intake, calorie count,

Code for Method

Codes for Self Assessment:

Code for Method

Codes for Self Assessment:

Prepares patients for GI diagnostic testing

Monitors NPO status and collaborates with MD and

Performs administration of enema, suppositories