CNA Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyPatient RightsCommunicates and obtains information while respecting the rights and privacy and confidentiality of information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 1 2 3 4 Involves the patient and family and respects their role in determining the nature of care to be provided, including Advance Directives. 1 2 3 4 Complies with nursing staff responsibility included in the hospital policy related to Organ Donation. 1 2 3 4 Meets patient and families needs regarding communication, including interpreter services. 1 2 3 4 Provides accurate information to patient and families in a timely manner. 1 2 3 4 Vital Signs and WeightsObtaining and Recording 1 2 3 4 BP, including Orthostatic 1 2 3 4 Pulse, Radia 1 2 3 4 Temperature, Oral 1 2 3 4 Temperature, Rectal 1 2 3 4 Temperature, Axillary 1 2 3 4 Temperature, Tympanic 1 2 3 4 Respirations 1 2 3 4 Weight, Pounds and Kilograms 1 2 3 4 Recognizing Cardiac Arrest 1 2 3 4 Activating Code Team 1 2 3 4 Bringing Emergency Equipment to Room 1 2 3 4 Providing Appropriate Code Support 1 2 3 4 Use of Electronic VS equipmentAutomatic BP machine (Dynamap) 1 2 3 4 Electronic Thermometer 1 2 3 4 Applying Oximeter 1 2 3 4 Scale UseStanding 1 2 3 4 Chair 1 2 3 4 Bed 1 2 3 4 GI /GUReport Abnormal Findings 1 2 3 4 Bowel Function 1 2 3 4 Bladder Function 1 2 3 4 Administering EnemasTap Water 1 2 3 4 Fleets 1 2 3 4 Return Flow 1 2 3 4 Vital Signs and WeightsPlacing and Removing Bed Pan 1 2 3 4 Clamping Catheter 1 2 3 4 Emptying Foley Bag 1 2 3 4 Placing Condom Catheter 1 2 3 4 Emptying and Replacing Ostomy Bag (Established Ostomy) 1 2 3 4 NutritionEstimating Intake 1 2 3 4 Setting up for Meals 1 2 3 4 Feeding Patients 1 2 3 4 Aspiration Precautions 1 2 3 4 Nourishments 1 2 3 4 Counting Calories 1 2 3 4 Fluid Restriction 1 2 3 4 NPO 1 2 3 4 SpecimensCollecting Stool 1 2 3 4 Collecting Sputum 1 2 3 4 Labeling Specimens and Preparing for Transport 1 2 3 4 Collecting UrineClean Catch 1 2 3 4 24 Hour 1 2 3 4 Hygiene /SkinRisk Factors for Skin Breakdown 1 2 3 4 Observing Pressure Points for Redness or Breakdown 1 2 3 4 Bathing / Daisy HygieneBathing (Shower / Tub / Arjo) 1 2 3 4 Oral Care, Including Patients who are NPO, Comatose 1 2 3 4 Pen Care 1 2 3 4 Foot Care for Patients with Impaired Circulation or Sensation 1 2 3 4 Incontinence Care 1 2 3 4 Shaving and Precautions 1 2 3 4 Reducing Pressure and Friction 1 2 3 4 Use of Pressure and Friction Reduction DevicesSpecial Beds/Mattresses 1 2 3 4 Heels and Elbow Protection 1 2 3 4 Foot Cradles 1 2 3 4 Use of Shower Chair 1 2 3 4 Use of Bath/Shower Boat 1 2 3 4 Infection ControlReverse Isolation 1 2 3 4 Body Substance Isolation 1 2 3 4 TB Precautions 1 2 3 4 MRSA Precautions 1 2 3 4 Hand Washing 1 2 3 4 Infectious/Hazardous Waste Disposal 1 2 3 4 Supply/Equipment Disposal 1 2 3 4 Use of Disposable Therrnometer 1 2 3 4 Use of CPR Mask/Bag 1 2 3 4 Proper use of Specific Barrier, MethodsGloves 1 2 3 4 Gown 1 2 3 4 Mask / Goggles 1 2 3 4 Safety and ActivityDetermining Patient ID 1 2 3 4 Identifying Safety Hazards 1 2 3 4 Determining Need for Additional Help 1 2 3 4 Assessing Safety and ADL Needs 1 2 3 4 Recognizing Abuse: Substance, Physical, Emotional, etc. 1 2 3 4 Maintaining Clean, Orderly Work Area 1 2 3 4 Disposing of Sharps 1 2 3 4 Handling Hazardous Materials 1 2 3 4 Proper Body Mechanics 1 2 3 4 ROM Exercises 1 2 3 4 Transferring to Bed, WC, Commode, etc. 1 2 3 4 Turning and Positioning 1 2 3 4 Patient Safety Module 1 2 3 4 Reporting Broken Equipment 1 2 3 4 Responding to Safety Hazards 1 2 3 4 Use of HoyerLift (Dextra /Maxi) 1 2 3 4 Bed Operation 1 2 3 4 Use of Wheel Locks 1 2 3 4 Use of Alarms: Bed, Patient, Unit 1 2 3 4 Use of CaIl Light 1 2 3 4 Documenting Use of Restraints 1 2 3 4 Use of Transfer Belt 1 2 3 4 Use of Gait Belt for Ambulation 1 2 3 4 Use of Seizure Pads 1 2 3 4 Application of RestraintsBelt Including Seat Belt 1 2 3 4 Wrist/Ankle 1 2 3 4 Vest 1 2 3 4 Care Routines: New Admissions and TransfersInventory and Disposition of Belongings, Use of Checklist 1 2 3 4 Room Orientation, Call Bell 1 2 3 4 Care Routines: Post-op PatientsTransferring into Bed 1 2 3 4 Call Bell 1 2 3 4 Assist with Turns 1 2 3 4 ROM Exercises 1 2 3 4 Maintaining 02 TherapyReplacing Mask or Nasal Caunula if Needed 1 2 3 4 Notifying Nurse of Problems 1 2 3 4 Basic Comfort Measures 1 2 3 4 Preparation For and Transfer to SNFEarly Bath 1 2 3 4 Preparing Belongings 1 2 3 4 Preparing for and Explaining Routines to Patient 1 2 3 4 Post Mortem Care 1 2 3 4 Use of Incentive Spirometer 1 2 3 4 Removing /ReplacingAntiembolic Stockings 1 2 3 4 Sequential Stockings 1 2 3 4 CommunicationUsing Appropriate Abbreviations 1 2 3 4 Identifying UnusuaI Patient Incidents that Require Reporting 1 2 3 4 Reinforcing RN Teaching With Patient 1 2 3 4 Selecting and Using Forms Appropriately 1 2 3 4 Using Alternate Communication Tools /Devices 1 2 3 4 Communicating to RNChanges in Patient Condition 1 2 3 4 Patient Needs, Complaints and Concerns 1 2 3 4 Unusual Incidents 1 2 3 4 Recording and ReportingVital Signs 1 2 3 4 Bathing /Hygiene 1 2 3 4 Turning and Repositioning 1 2 3 4 Ambulation and Activity 1 2 3 4 Diet intake, Calorie Count 1 2 3 4 Bowel Movements 1 2 3 4 1 & 0Shift Volumes and Totals 1 2 3 4 Marking and / or Measuring Amount of Urine, Gastric Fluid, NG Drainage, Emesis, Diarrhea 1 2 3 4 Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 Unit ActivityIdentifying Unusual Incidents on the Unit that Require Reporting 1 2 3 4 Locating and Using Appropriate Reference Materials: Hospital, Patient Care 1 2 3 4 Charging for Patient Care Items 1 2 3 4 Completing Risk Management Reports as Needed 1 2 3 4 Obtaining Needed Supplies and Equipment 1 2 3 4 Reporting and Following up on Faulty Equipment and Supplies 1 2 3 4 Using Telephone System 1 2 3 4 AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Case Management Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
