CNA skills checklist.pdf - haspi

State of California—Health and Human Services AgencySAMPLE FORM(May be used by provider)NURSE ASSISTANT TRAINING PROGRAMSKILLS CHECK LISTCalifornia Department of Public HealthLicensing and Certification ProgramAide and Technician Certification Section (ATCS)1615 Capitol Avenue, MS 3301P.O. Box 997416Sacramento, CA 95899-7416(916) 327-2445 FAX (916) 552-8785Student name Enroll date Social security numberTraining program Completion date Clinical site nameInstructor’s name Title InitialsSignatureClinicalDateClinicalDateHoursHoursS = Satisfactory U = UnsatisfactoryNURSE ASSISTANT TRAINING PROGRAMSKILLS DEMONSTRATED S/U Comments Date PerformedModule 6, Medical and Surgical Asepsis (8 Hours Clinical)1. Hand washing2. Proper handling of linen3. Universal precautions! Gloving! Gowning! Apply mask4. Double bagging trash/wasteModule 5, Body Mechanics (4 Hours Clinical)1. Use of gait belt2. Helping the helpless resident up to the head of thebed with two assistants3. Turning and positioning the resident! Supine! Side-lying!" Use of lift sheet4. Assisting transfer from bed to chair or wheelchair5. Assisting transfer from chair or wheelchair to bed6. Mechanical liftModule 2, Resident’s Rights (1 Hour Clinical)1. Knocks on door before entering2. Pulls privacy curtains during personal care3. Keeps resident information confidential4. Treats resident with respect and dignity5. Encourages resident to make choices6. Explains procedure to residentHS 276 A (9/08) This form is available on our website at www.cdph.ca.govLicensed NurseInitialsPage 1 of 4

NURSE ASSISTANT TRAINING PROGRAMSKILLS DEMONSTRATED S/U Comments Date PerformedModule 14, Rehabilitative/Restorative Care (4 HoursClinical)1. Range of motion exercises2. Assisted ambulation of resident with gait belt3. Assisting the resident to ambulate with walker4. Assisting the resident to ambulate with cane5. Rehabilitative devices Type:Module 4/12, Emergency Procedures and Prevention ofCatastrophe (2 Hours Clinical)1. Applying postural supports (safety devices)2. Applying soft wrist/ankle restraint as safety device3. Heimlich maneuver for the conscious resident4. Heimlich maneuver for the unconscious resident5. Positioning of call light6. Demonstrates fire/disaster procedures7. Handles O 2 safely8. Use of fire extinguisherModule 8, Patient Care Skills (44 Hours Clinical)1. Back rub2. Bed bath/partial bath3. Tub bath4. Shower5. Assisting with oral hygiene6. Mouth care of the unconscious resident7. Denture care8. Nail care9. Combing the resident’s hair10. Shampoo of bedridden resident11. Shampoo with shower or tub bath12. Medicinal shampoo13. Shaving—electrical shaver14. Shaving—razor blade15. Dressing and undressing the resident16. Changing the clothes of resident with IV17. Assist in the use of urinal18. Assist in the use of the bedpan19. Assisting resident to commode/toilet20. Bladder retraining21. Bowel retraining22. Perineal care23. Artificial limbs24. Splints25. Applying a behind-the-ear hearing aid26. Removing a behind-the-ear hearing aidLicensed NurseInitialsHS 276 A (9/08) This form is available on our website at www.cdph.ca.govPage 2 of 4

NURSE ASSISTANT TRAINING PROGRAMSKILLS DEMONSTRATED S/U Comments Date Performed27. Removing, cleaning, and reinserting an artificial eyeLicensed NurseInitialsModule 10, Vital Signs (6 Hours Clinical)Measure and Record Vital Signs! Temperature! Oral! Axillary! Rectal! Electronic!" Pulse: radial!" Pulse: apical! Respiration! Blood pressureModule 9, Resident Care Procedures (20 Hours Clinical)1. Collect and identify specimen! Sputum specimen!" Urine specimen: clean catch!" Urine specimen: routine UA! Stool specimen2. Occupied bed making3. Unoccupied bed making4. Administering the commercially prepared cleansingenema5. Administering enemas—tap water, soap suds6. Administering laxative suppository7. Empty urinary bags8. Care of resident with tubing! Oxygen! IV! Gastrostomy! Nasogastric! Urinary catheter9. Antiembolic hose, elastic stockings (TED Hose)10. Admitting the resident11. Transferring the resident12. Discharging the resident13. Application of nonsterile dressing14. Application of nonlegend topical ointmentsModule 7, Weights and Measures (1 Hour Clinical)1. Measuring oral intake2. Measuring urinary output3. Measuring the height of resident in bed4. Weighing the resident in bed5. Measuring and weighing the resident using an uprightscaleHS 276 A (9/08) This form is available on our website at www.cdph.ca.govPage 3 of 4

NURSE ASSISTANT TRAINING PROGRAMSKILLS DEMONSTRATED S/U Comments Date Performed6. Documents in military timeModule 11, Nutrition (6 Hours Clinical)1. Feeding the helpless resident2. Assisting the resident who can feed self3. Verifying that resident has been given correct diettray4. Use of feeding assistance devicesModule 15, Observation and Charting (4 Hours Clinical)1. Reports appropriate information to charge nurse2. Documents V/S, ADLs timely/correctly3. Documents changes in resident’s bodyfunctions/behavior4. Participates in resident care planningLicensed NurseInitialsHS 276 A (9/08) This form is available on our website at www.cdph.ca.govPage 4 of 4