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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
**

2013 patients/orders.
Moderate Sedation: Not applicable to paramedics
Gathers appropriate patient
monitoring equipment.
Verifies informed consent from
provider.
Administers medication per MD
directions.
Documents procedure in EMR.
Assesses patient during procedure
and post-procedure appropriately
(per Piedmont policy and/or
Lippincott procedure).
Orthopedic injuries:
Demonstrates appropriate
identification, intervention and care
of patients with orthopedic injuries.

Rapid Sequence Intubation: Not applicable for paramedics
Verbalizes criteria for RSI.
Communicates understanding of RNs
responsibility during RSI. 6 Ps of RSI

Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 19