APRN - Department of Nursing

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INITIAL UMG/JDH AMBULATORY COMPETENCY CHECKLIST 10 of 12 Position Title: Nurse Practitioner Department: Psychiatry Employee Name: Method of Instruction Key: P = Protocol/Procedure Review E = Education Session S = Self Learning Package C = Clinical Practice D = Demonstration Method of Evaluation Key: O = Observation (in clinical setting) RD = Return Demonstration T = Written Test V = Verbal Review Method of Instruction (Use Instruction Key on Left) Evaluation Summary Evaluation Method (Use Evaluation Key on Left) Comments Competent Initials Date Yes No Laboratory Age Specific Unit Specific Corporate Compliance HIPAA Attends job related in-services throughout the year CEUs for certification Attends clinic staff meetings as scheduled. Initiates membership to the UCHC nurse practitioner forum Maintains BCLS certification See Unit Specific Page Initials/Name: ___us/Ute Schroeder___________ Initials/Name: ______________________________ Initials/Name: __________________________ Competency Checklist Updated: 9/05, 7/07, 1/08, 4/08
INITIAL UMG/JDH AMBULATORY COMPETENCY CHECKLIST 11 of 12 Position Title: Nurse Practitioner Department: Psychiatry Employee Name: Method of Instruction Key: P = Protocol/Procedure Review E = Education Session S = Self Learning Package C = Clinical Practice D = Demonstration Method of Evaluation Key: O = Observation (in clinical setting) RD = Return Demonstration T = Written Test V = Verbal Review Method of Instruction (Use Instruction Key on Left) Evaluation Summary Evaluation Method (Use Evaluation Key on Left) Comments Competent Initials Date Yes No UNIT SPECIFIC CHECKLIST: III. EQUIPMENT “Clinical Database” for Department of Psychiatry Hippocrates software IV. DOCUMENTATION/COMMUNICATION Documents on or reviews documentation/use of: Charge sheet Ambulatory Summary List Complies with approved policies and guidelines regarding patient Release of Information (use of HCH 551 “Authorization to Obtain and/or Disclose Health Information”) Utilizes “Treatment Transfer Form” when referring patients within Department of Psychiatry. (i.e. referring to addiction clinic or other Provider) V. PERFORMANCE IMPROVEMENT Participates in patient safety and performance improvement chart audits VII. PROVISION OF CARE Utilizes the following forms for patient assessment, formulation of treatment plan, and evaluation: “Out Patient Psychiatric Risk Screen” form “Intake Self Assessment” PHQ9 (Depression screening scale) AIMS (Abnormal involuntary movement scale) Conducts Group Therapy sessions Initials/Name: ___us/Ute Schroeder___________ Initials/Name: ______________________________ Initials/Name: __________________________ Competency Checklist Updated: 9/05, 7/07, 1/08, 4/08
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APRN - Department of Nursing

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