Healthcare Competency Answer Sheet

HEALTHCARE COMPETENCY ANSWER SHEET

Facility and Assessment Information

Facility Name:    Department:

Evaluator Name:    Date of Assessment:

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History (brief)

Instructions for Candidate

This sheet documents the patient's responses and demonstrated understanding for defined competencies. Answer each question fully. The evaluator will observe demonstrations where required and record pass/fail and comments. Completion of this form constitutes inclusion of the competency results in the patient record and may be used for care planning and follow-up training.

Competency Items and Answers

1. State your full name and date of birth. Answer:

Result: Pass    Fail

2. Describe the purpose and dosing schedule of one of your prescribed medications. Answer:

Result: Pass    Fail

3. Demonstrate the correct technique for using your inhaler, oxygen device, or mobility aid. Summarize demonstration steps:

Result: Pass    Fail

4. Identify at least three warning signs that require immediate medical attention. Answer:

Result: Pass    Fail

5. Describe your wound care or dressing change procedure as taught. Answer:

Result: Pass    Fail

6. Explain how and when to contact your primary care provider or emergency services. Answer:

Result: Pass    Fail

Scoring and Evaluator Comments

Total Items Assessed:    Items Passed:    Final Determination: Competent Needs additional training

Legal Certification and Patient Acknowledgment

By signing below I certify under penalty of administrative sanction that the answers and demonstrations provided on this competency sheet are true and accurate to the best of my knowledge. I understand that this competency evaluation will be included in my medical record and shared with members of my care team as necessary for treatment, safety, and care coordination.

I acknowledge that I have the right to ask questions, request additional instruction or to refuse any part of the competency demonstration. I understand that if I do not demonstrate required competencies, additional training or support will be provided and re-evaluation scheduled. I authorize release of the competency results to my designated caregivers and authorizing clinicians for purposes of ongoing care.

HIPAA Privacy Acknowledgment: I acknowledge that I have been informed of privacy protections and that the competency record is subject to medical record confidentiality protections.

Authorization Expiration Date (if applicable):

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