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INITIAL PERFORMANCE VALIDATION: END OF ASSESSORS’ INITIALS & SIGNATURES
SELF ASSESSMENT Validation Methods: 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
**
CONTINUUM OF CARE:
Uses emergency nursing process to
assess, plan, implement and evaluate
nursing care.
Documents effectively all patient care
aspects; including interventions,
patient’s responses to interventions,
progress in healing and any significant
events in the care process.
Communicates critical information
effectively healthcare providers and
clinical staff during handoff using the
specified method [ex. SBAR].
Participates in discharge planning per
Piedmont policy or as indicated by
Lippincott procedures.
Transfers patients effectively (ex.
interdepartmental, interfacility,
Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 6
