AURORA HOSPICE, INC. ADDENDUM 3-002.D Employee Self Assessment Employee Name First Middle Last Suffix Experience with these skills: A. Demonstrates ability to process paperwork & associated functions necessary to facilitate: 1. Patient admission to Aurora Hospice Agency a) Completes initial nursing assessment Yes No b) Initiates care plan based on initial assessment Yes No c) Complete knowledge of nursing process Yes No d) Health history/physical exam Yes No 2. Knowledge of the Medicare Hospice Benefit a) Patient rights and responsibilities Yes No b) Hospice services available Yes No c) Conditions of Participation requirements Yes No 3. Concepts of Death & Dying a) Normal vs abnormal Yes No b) Cultural attitudes toward death Yes No c) Values of patient/family Yes No d) Denial and coping mechanisms Yes No e) Grief and family, children and others Yes No f) Anticipatory grief Yes No 4. Hospice concept and philosophy of care a) Treating the family and the patient as the unit of care Yes No b) Participation in the Interdisciplinary Group Yes No c) Demonstrating continuity of care at inpatient/alternate settings Yes No d) Philosophy of comfort, dignity, quality of life and empowerment Yes No 5. Documentation a) Medicare guidelines for documentation Yes No b) Corrections to the medical record Yes No c) Accident/incident reports Yes No d) Clinical notes, flow charts Yes No B. Review of Systems: Demonstrates ability to obtain and document appropriate age specific history/assessment for patients in the following categories: 1. Symptom Assessment/Management a) Nausea/vomiting Yes No b) Fluid/electrolyte imbalance Yes No c) Weight loss/nutritional deficiency Yes No d) Diarrhea Yes No e) Constipation Yes No f) Skin breakdown/lesions Yes No g) Weakness/fatigue Yes No h) Edema Yes No i) Dyspnea Yes No j) Cognitive impairment Yes No k) Depression Yes No l) Urinary incompetence/retention Yes No 2. Pulmonary System a) Pulmonary assessment Yes No b) Tracheostomy Care Yes No c) Oxygen Administration Yes No d) Use of Oral/Nasal Inhalents Yes No e) Oxygen Mask, Nasal Cannula, Concentrator Yes No f) SVN/Nebulizer Treatment Yes No g) Foreign Body Airway Obstruction Yes No h) Breathing Exercises/Incentive Spirometry Yes No 3. Cardiovascular System a) Cardiovascular Assessment Yes No b) Pulses (apical, radical, femoral, pedal) Yes No c) Edema Assessment and Management Yes No d) Supine and Orthostatic Blood Pressure Yes No e) CPR Yes No f) Energy Conservation Techniques Yes No 4. Gastrointestinal System a) Gastrointestinal Assessment Yes No b) Nutritional Assessment Yes No c) Ostomy Care Yes No d) Dysphagia Precautions Yes No e) Impaction Removal Yes No f) Enema Yes No g) Bowel Training Yes No 5. Genitourinary System a) Urinary Catheterization Insertion & Care Yes No b) Irrigation of Catheters Yes No c) Removal of Urinary Catheter Yes No d) Care of Supra-Pubic Catheter Yes No e) Care of Urostomy Yes No f) Bladder Training Yes No g) Nephrostomy Tubes Yes No h) Incontinence Care Yes No 6. Integumentary/Wounds/Dressings a) Assessment of Skin Yes No b) Measurement of Wounds Yes No c) Wound Irrigation Yes No d) Dressing Change Yes No e) Decubitis Care Yes No f) Ace Wrap, Compresses Yes No 7. Pain Assessment and Management a) Conducts pain evaluation/assessment Yes No b) Utilizes a pain rating scale to collect data Yes No c) Knowledgeable about types of pain Yes No d) Knowledgeable about drug therapies indication and dosing Yes No e) Patient/Family Teaching Yes No 8. Behavioral Assessments a) Psychosocial Status Yes No b) Suicide Precautions Yes No c) Care of the Demented Patient Yes No d) Spiritual Yes No e) Grief Yes No C. MEDICATION ADMINISTRATION: Demonstrates ability to administer, monitor and document medications for patients 1. Medication Administration Techniques a) Oral Yes No b) Suppositories Yes No c) Insulin Administration, Site Rotation Yes No d) Assessment for side effects, adverse reactions, therapeutic response Yes No D. INFECTION CONTROL 1. Handwashing Technique Yes No 2. Aseptic Technique Yes No 3. Proper Bag Technique Yes No 4. Personal Protective Equipment Yes No 5. TB Exposure Control Plan Yes No 6. Reporting of Infections for Patient and Staff Yes No 7. Standard Precautions Yes No E. SAFETY 1. Restraints, Indications and Policy Yes No 2. Fire Extinguishers Yes No 3. Emergency Preparedness Yes No 4. Assessment of Patient Safety Risks and Home Safety Yes No F. PATIENT EDUCATION 1. Determine Patient and Family Learning Needs Yes No 2. Develops/Implements Teaching Plan Yes No 3. Evaluates Effectiveness of Teaching Yes No 4. Revises Teaching Plan based on Patient Needs Yes No 5. Documents Response to Teaching Yes No 6. Provides instruction about advance directives and Patient Rights Yes No 7. Disease Process Yes No 8. Death & Dying Yes No 9. Grief Process Yes No Employee Signature: Sign above Date: Leave this field blank