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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
**
Verbalizes correct process to take for
patients who fail the swallow
assessment.
Verbalizes correct interventions for
patients at risk for aspiration.
AMI Pathway:
Verbalizes how to recognize signs and
symptoms of AMI.
Verbalizes process for activating AMI
pathway.
Blood Administration: Not applicable to Paramedics
Demonstrates correct blood
administration process.
CAUTI: Not applicable to Paramedics
Demonstrates correct documentation
and management of Urinary catheter.
Utilizes CAUTI promise package
appropriately.
Demonstrates appropriate urinary
catheter insertion techniques per
Piedmont policy and Lippincott
procedures.
CLABSI: Not applicable to Paramedics
Demonstrates correct documentation
Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 14