Healthcare Competencies Document

HEALTHCARE COMPETENCIES DOCUMENT

Purpose: This document records the demonstration and verification of clinical and professional competencies required for performance in the assigned healthcare role. Completion and signature indicate that the employee has been assessed on the listed competencies and that the evaluator has documented observations and required remediation, if any. This record becomes part of the employee's personnel file and may be relied upon for privileging, assignment, and training purposes.

1. Employee Information

Employee Name:

Date of Birth:    Gender:

2. Position & Employment Information

Supervisor Name:    Date of Hire:

3. Licenses, Certifications, and Training

Please indicate current certifications held (check all that apply):

BLS (Basic Life Support)    ACLS (Advanced Cardiac Life Support)    PALS (Pediatric Advanced Life Support)

IV Therapy Certification    Registered Nurse License    Other (specify below)

4. Competency Assessment (Evaluator to complete)

Scoring legend: Demonstrated = competency performed independently and to standard; Needs Improvement = requires supervised practice and remediation; Not Applicable = skill not required for assigned role.

1. Vital signs measurement and interpretation — Demonstrated Needs Improvement Not Applicable Date: Evaluator Initials:

2. Medication preparation, dosage calculation, and safe administration — Demonstrated Needs Improvement Not Applicable Date: Evaluator Initials:

3. Intravenous insertion and management (when applicable) — Demonstrated Needs Improvement Not Applicable Date: Evaluator Initials:

4. Patient assessment and care planning — Demonstrated Needs Improvement Not Applicable Date: Evaluator Initials:

5. Emergency response and escalation (including use of emergency equipment) — Demonstrated Needs Improvement Not Applicable Date: Evaluator Initials:

6. Infection prevention and hand hygiene compliance — Demonstrated Needs Improvement Not Applicable Date: Evaluator Initials:

7. Clinical documentation accuracy and timeliness — Demonstrated Needs Improvement Not Applicable Date: Evaluator Initials:

5. Training & Remediation

Training Date:    Training Provider:

Refresher Required: Yes No

6. Privacy and Record Use

By signing below, the employee acknowledges that competency records constitute personnel and quality assurance records. Access to this record is restricted to authorized personnel. The employee further acknowledges receipt of and compliance with applicable patient privacy policies and that any disclosure of protected health information will be in accordance with organizational policy and applicable law.

Acknowledgement of Privacy Policy and HIPAA training completion: I acknowledge I have received and completed required privacy/HIPAA training.

7. Certification and Signatures

Certification by signing parties: The employee attests that the information provided is true and complete to the best of their knowledge. The evaluator certifies that the competency assessments and comments represent direct observation or documented review, and that remediation plans, if any, are reasonable and recorded above. Falsification or omission of material facts may result in disciplinary action up to and including termination.

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