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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
**
documentation and care.
Rapid Response/STAT team:
Uses MEWS to identify patients at risk
of decline.
Activates Rapid Response/STAT team
as appropriate. (Only applicable to ED
Boarder patients).
Sepsis Pathway:
Verbalizes how to recognize signs and
symptoms of sepsis.
Verbalizes process for activating
Sepsis pathway.
Stroke Pathway:
Verbalizes how to recognize signs and
symptoms of stroke.
Verbalizes process for activating
Stroke pathway.
Demonstrates correct MEND exam
technique and documentation.

Demonstrates correct TPA
documentation.
Ventilator Assisted Event:

Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 16