* Required Information
Staff Member Name
*
Date of Hire
Patient MR Number
Period of review from
To
Type of visit
*
Quarterly
Annual
New procedure/equipment
Teaching/training
Staff member request
Other
1. Maintains professional demeanor and appearance (dress, identification)
*
Yes
No
N/A
Initials
*
Comments
*
2. Communicates effectively
*
Yes
No
N/A
Initials
*
Comments
*
3. Identifies and responds to patient needs
*
Yes
No
N/A
Initials
*
Comments
*
4. Reviews and follows plan of care
*
Yes
No
N/A
Initials
*
Comments
*
5. Completes a patient assessment/reassessment and documents appropriately
*
Yes
No
N/A
Initials
*
Comments
*
6. Involves patient in care planning
*
Yes
No
N/A
Initials
*
Comments
*
7. Practices appropriate infection control (CPR mask, hand washing, bag technique)
*
Yes
No
N/A
Initials
*
Comments
*
8. Practices safety procedures
*
Yes
No
N/A
Initials
*
Comments
*
9. Is organized and productive
*
Yes
No
N/A
Initials
*
Comments
*
10. Schedules next visit, DC planning (if appropriate)
*
Yes
No
N/A
Initials
*
Comments
*
11. Exhibits skill/equipment proficiency
*
Yes
No
N/A
Initials
*
Comments
*
12. Demonstrates teaching/training
*
Yes
No
N/A
Initials
*
Comments
*
13. Completes documentation
*
Yes
No
N/A
Initials
*
Comments
*
14. Other
*
Other
*
Yes
No
N/A
Initials
*
Comments
*
Supervisor initial
*
Date
Staff initial
*
Date
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