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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
**
Demonstrates correct documentation
and utilization of VAE prevention
bundle (per Piedmont policy and/or
Lippincott procedures).
VTE prevention:
Explains pharmacological and
mechanical intervention measures to
prevent VTE and associated
documentation.
Demonstrates correct measurement,
application and process for IPC
therapy.
HIGH RISK/LOW VOLUME COMPETENCIES:
BiPap:
Demonstrates the appropriate
assessment, interventions, nursing
considerations, and management of
patients on BiPap.
CODE Blue:
Demonstrates the appropriate
response to a code blue, and use of
the Code Narrator.
Communicates understanding and
location of emergency
Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 17