AURORA HOSPICE, INC. ADDENDUM 3-002.D Employee Self Assessment Employee Name First Middle Last Suffix Experience with these skills: 1. Temperature: a) Oral Yes No b) Axillary Yes No c) Digital Thermometers Yes No 2. Pulse (radial) Yes No 3. Respiration Yes No 4. Bed Bath Yes No 5. Shower/Tub Bath/Sponge Bath Yes No 6. Nail Care Yes No 7. Skin Care Yes No 8. Oral Care Yes No 9. Shampoo Yes No 10. Toileting/Elimination: a) Urinal Yes No b) Bedpan Yes No 11. Transfer Techniques: a) Bed to Chair Yes No b) Chair to standing Yes No c) Assist with ambulation Yes No d) Hoyer Lift Yes No 12. Assists with normal range of motion and positioning Yes No 13. Assistive Devices: a) Walker Yes No b) Cane Yes No 14. Documentation Skills: (legible, timely, accurate & complete) a) Incident Reporting Yes No b) Relates to Plan of Care Yes No 15. Observation and Reporting to: a) RN/Case Manager Yes No b) Administrative personal Yes No c) Other Hospice Disciplines Yes No 16. Adheres to Plan of Care: a) Reviews Plan of Care prior to care Yes No b) Performs services as ordered Yes No c) Documents according to Plan of Care Yes No 17. Infection Control: a) Hand washing Yes No b) Proper bag technique Yes No c) Protective equipment Yes No d) Exposure Plan Yes No e) Equipment Care Yes No 18. Reports and Documents Key Information to Case Manager and/or Supervisor Yes No 19. Emergency Problems Yes No 20. Patient Safety/Falls Risk Yes No 21. Meal Preparation: a) Feeding Yes No b) Diabetic Diet Yes No c) Low Sodium Yes No d) Low Cholesterol/Fat Yes No 22. Light Housekeeping Yes No 23. Linen Change/Wash Clothing Yes No 24. Hospice Concept and Philosophy of Care: a) Treating the patient/family as the unit of care Yes No b) Palliative Care approaches Yes No c) Interdisciplinary practice Yes No d) Demonstrating continuity of care at inpatient settings; alternate settings Yes No e) Philosophy of comfort, dignity, autonomy, quality of life and empowerment Yes No 25. Concepts of Death and Dying: a) Normal vs. abnormal Yes No b) Cultural attitudes toward death Yes No c) Values of patient/family Yes No d) Grieving and fears of dying patient Yes No e) Denial and defense mechanisms Yes No f) Grief and family, children and others Yes No g) Anticipatory grief Yes No 26. Communication Skills: a) Eye Contact, active listening Yes No b) Avoiding interruptions and judgmental responses Yes No c) Support and reassurance Yes No 27. Acceptance of differing cultures/religious values Yes No 28. Handling a death at home Yes No Employee Signature: Sign above Date: Leave this field blank