Healthcare Competency Sheet

HEALTHCARE COMPETENCY SHEET

Patient Identification

Patient Name:

Insurance / Responsible Party

Medical History Summary

Competency Assessment

Assessor Name:   Title:

Date of Assessment:   Location/Unit:

For each competency below, indicate demonstrated level at the time of assessment. Mark all that apply and provide comments where required.

Administrative Attestations

Assessor Attestation: I attest that the competencies listed above were evaluated directly by me or under my supervision and that the assessment reflects the patient's observed skills on the date documented. Assessor Printed Name:

Assessor License / Credential #:   Date:

Patient Certification and Acknowledgment

I acknowledge that I have participated in the competency assessment described above. I have been informed of the results, the recommended interventions, and the risks and benefits associated with the level of independence identified. I understand that I have the right to ask questions, to request additional instruction at any time, and to withdraw my consent for non-emergent procedures.

By signing below I certify that the information I have provided on this form is true to the best of my knowledge and that I accept the care plan and recommendations recorded. I understand that this competency assessment is part of my medical record and will be retained according to facility policy.

I acknowledge receipt of the facility's privacy practices and understand that my protected health information may be used and disclosed for treatment, payment, and health care operations as permitted by law. I may revoke authorizations in writing except to the extent action has already been taken in reliance on such authorization.

Authorization Expiration Date:

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