Healthcare Nurse Competency Checklist

Healthcare Nurse Competency Checklist

Purpose: This form documents the assessment of clinical knowledge, technical skills, professional judgment, and adherence to facility policies for the nurse named below. Completion of this checklist constitutes an official record of competency for privileging, orientation, annual evaluation, or focused reassessment. Information recorded herein is a confidential personnel record and will be retained in accordance with facility policy.

Nurse Information

Evaluation Details

Initial Annual Re-evaluation Focused

Competency Checklist

Rating columns: Observed (O), Demonstrated (D), Competent (C), Requires Remediation (R). For each skill, mark all applicable and record the date of assessment.

1. Clinical Assessment — Performs comprehensive head-to-toe assessment, recognizes changes in condition, documents findings. Observed: Demonstrated: Competent: Requires remediation: Date:

2. Medication Administration — Correct medication verification, dose calculation, five rights, safe administration, monitoring for adverse reactions. Observed: Demonstrated: Competent: Requires remediation: Date:

3. IV Therapy / Infusion Management — Initiates IVs, manages infusion devices, monitors insertion site and complications. Observed: Demonstrated: Competent: Requires remediation: Date:

4. Wound Care and Dressing Changes — Performs appropriate wound assessment, dressing technique, and documentation. Observed: Demonstrated: Competent: Requires remediation: Date:

5. Urinary Catheter Care — Inserts (if privileged), maintains, irrigates, and documents catheter care according to policy. Observed: Demonstrated: Competent: Requires remediation: Date:

6. Documentation and Electronic Medical Record — Accurate, timely, and complete charting; proper use of flowsheets and orders. Observed: Demonstrated: Competent: Requires remediation: Date:

7. Infection Prevention and Aseptic Technique — Hand hygiene, PPE selection, isolation precautions, sterile technique when indicated. Observed: Demonstrated: Competent: Requires remediation: Date:

8. Emergency Response / Code Management — Initiates appropriate response, ACLS/BLS roles, crisis communication, transfers. Observed: Demonstrated: Competent: Requires remediation: Date:

9. Patient Education and Discharge Teaching — Provides education appropriate to patient needs, documents comprehension and follow-up. Observed: Demonstrated: Competent: Requires remediation: Date:

10. Safe Patient Handling and Mobility — Uses devices and team techniques to minimize risk and maintain patient safety. Observed: Demonstrated: Competent: Requires remediation: Date:

Overall Competency Determination

Based on the items assessed above, mark the overall determination. If remediation is required, provide a remediation plan below with responsible trainer and dates.

Meets expectations / Competent Conditional — requires supervised practice Not competent — requires immediate action

Evaluator Attestation

I attest that the competencies checked on this form were assessed through direct observation, simulation, or return demonstration. All assessments were conducted according to facility policy and professional standards. I further attest that the nurse's license and required certifications were verified for currency at the time of this evaluation.

Evaluator Signature (for internal record):   Date:

Confidentiality and Record Notice

This competency record is a confidential personnel document maintained in the employee file. Disclosure of information contained in this form is limited to individuals with a need to know and as permitted by law and facility policy. Retention and destruction of this document will follow applicable record retention schedules.

By signing below, the nurse acknowledges receipt of this evaluation, understands the outcomes, and accepts responsibility to participate in any required remediation.

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