Hospice Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information HiddenOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security Number Email(Required) HiddenDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWORK SETTINGSHome Hospice(Required) 1 2 3 4 Inpatient Hospice(Required) 1 2 3 4 Home Health/Hospice Setting(Required) 1 2 3 4 ASSESSMENTIntake Assessment(Required) 1 2 3 4 Assessment Interview(Required) 1 2 3 4 Physical Exam(Required) 1 2 3 4 Coping Status(Required) 1 2 3 4 Environmental Status(Required) 1 2 3 4 PLAN OF CARESet Goals with Pt/Family(Required) 1 2 3 4 Collaborate with Other Team Members(Required) 1 2 3 4 Ensure Continuity of Care(Required) 1 2 3 4 SYMPTOM MANAGEMENTUrgent Assessment of Symptoms(Required) 1 2 3 4 Reduce Symptoms to Level Acceptable to Pt.(Required) 1 2 3 4 Report Symptoms/Management to Provider(Required) 1 2 3 4 Treat Underlying Cause(Required) 1 2 3 4 Severity Scale(Required) 1 2 3 4 Management of Nausea(Required) 1 2 3 4 Management of Constipation(Required) 1 2 3 4 Management of Fatigue(Required) 1 2 3 4 Anorexia/Cachexia(Required) 1 2 3 4 Restlessness(Required) 1 2 3 4 Educate Family on Symptom Management(Required) 1 2 3 4 PAIN MANAGEMENTIdentify Source of Pain(Required) 1 2 3 4 Pain Severity(Required) 1 2 3 4 PAINAD Scale for Non Verbal Patient(Required) 1 2 3 4 Reduce Pain to Level Acceptable to Patient(Required) 1 2 3 4 WHO 3 Step Ladder(Required) 1 2 3 4 Non-Pharmacologic Management of Pain(Required) 1 2 3 4 Pharmacologic Management of Pain(Required) 1 2 3 4 Effects of Pharmacologic Treatment(Required) 1 2 3 4 Nociceptive/Neuropathic/Mixed Pain(Required) 1 2 3 4 Management of Nociceptive Pain(Required) 1 2 3 4 Educate Family on Pain Management(Required) 1 2 3 4 WOUND CAREPositioning Techniques(Required) 1 2 3 4 Bed/Support Surface Selection(Required) 1 2 3 4 Pressure Ulcer Staging/Management(Required) 1 2 3 4 Response to Treatment(Required) 1 2 3 4 Evaluate Factors that Impede Healing(Required) 1 2 3 4 Educate Family on Positioning/Shearing(Required) 1 2 3 4 PEDIATRICSDevelopmentally Appropriate Assessment(Required) 1 2 3 4 Parental/Sibling Support(Required) 1 2 3 4 Pediatric Support Team Collaboration(Required) 1 2 3 4 MEDICATION ADMINEquianalgesic Conversion Formula(Required) 1 2 3 4 Titration of opioids(Required) 1 2 3 4 IV Pump Management(Required) 1 2 3 4 Evaluate Effectiveness of Medications(Required) 1 2 3 4 Family Management of Medications(Required) 1 2 3 4 Disposal of Medications(Required) 1 2 3 4 AFTER DEATHFacility Family/Cultural Rituals/Rites(Required) 1 2 3 4 Patient Care after Death(Required) 1 2 3 4 Coordinate Mortuary Services(Required) 1 2 3 4 Bereavement Services(Required) 1 2 3 4 COMPLIANCEScope and Frequency of Services(Required) 1 2 3 4 Medicare/State Regulations for Hospice(Required) 1 2 3 4 Document Progression of Decline(Required) 1 2 3 4 DME Authorization & Documentation of Need/Order(Required) 1 2 3 4 OASIS-C(Required) 1 2 3 4 PROFESSIONAL KNOWLEDGE AND SKILLSIdentify Source of Suffering(Required) 1 2 3 4 Palliative Care Philosophy(Required) 1 2 3 4 Patient/Family Directs Goals of Care(Required) 1 2 3 4 Maximize Quality of Life(Required) 1 2 3 4 Cultural Diversity(Required) 1 2 3 4 Supervision of Ancillary Staff(Required) 1 2 3 4 National Patient Safety Goals/Core Measures(Required) 1 2 3 4 Fall Risk Assessment/Prevention(Required) 1 2 3 4 Infection Prevention(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 Interpretation and Communication of Lab Values(Required) 1 2 3 4 EMREpic(Required) 1 2 3 4 Cerner(Required) 1 2 3 4 Eclipsys(Required) 1 2 3 4 Allscripts(Required) 1 2 3 4 McKesson(Required) 1 2 3 4 Meditech(Required) 1 2 3 4 Other Computerized System(Required) 1 2 3 4 Computerized Physician Order Entry(Required) 1 2 3 4 Bar Coding for Medication Administration(Required) 1 2 3 4 EMR Conversion(Required) Yes No CERTIFICATIONSBLS(Required) Yes No BLS Expiry DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CHPN(Required) Yes No CHPN Expiry Date :Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ACHPN(Required) Yes No ACHPN Expiry Date :Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CHPPN(Required) Yes No CHPPN Expiry Date :Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Other: Specify Other Expiry Date :Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. 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