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INITIAL PERFORMANCE VALIDATION: END OF ASSESSORS’ INITIALS & SIGNATURES
Validation Methods:
SELF ASSESSMENT
ORIENTATION
SKILLS / TASKS and/or VALIDATION O = Observed performance SELF ASSESSMENT _________ _____________________________
PROCEDURES and/or D = Skills Lab demo/ VALIDATION _________ _____________________________
performance

EQUIPMENT Date: _______________ L = Learning assessment
form/Test Date: ________ _________ _____________________________
C = Chart review

V = Verbalized _________ _____________________________
Check 1 column below: PR = Policy Review Check 1 column:
N/A = Not applicable or no
opportunity at the facility

Date Met &
Assessor Initials:
Can Need Never Validation Task completed or Can Do Need COMMENTS:
Do Review done Methods: Procedure Review Needs Review?
Performed
Correctly
**
applicable policies and procedures.
Collaboration with each patient
/family /significant other in order to
address identified needs.
Implements preventive interventions
for patients who are at risk for
pressure ulcers per Piedmont policy &
Lippincott procedures.
Implements appropriate interventions
to prevent patient falls and
documents per Piedmont policy &
Lippincott procedures.
Implements appropriate interventions
to prevent the spread of infections
[ex. hand washing, PPE]. Per Piedmont
policy & Lippincott procedures.

Prepares and administers medications
correctly using safety standards [ex.
ID checking, armband checking] and
documents.

Demonstrates application of restraints

Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 5