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Hospice RN Skills Checklist

Please rate your experience / frequency within the last year

0 = No Experience / Observed Only
1 = Limited Experience / Rarely Done (<6 times/year)
2 = May Need Some Review / Occasionally Done (1 – 2 times/month)
3 = Experienced / Frequently Done (daily or weekly)

MM slash DD slash YYYY

AGE OF PATIENTS CARED FOR

Newborn/ Neonate (birth to 30 days)(Required)
Infant (1 month to 1 year)(Required)
Toddler (1 year to 3 years)(Required)
Preschooler (3 years to 5 years)(Required)
School Age Child (5 years to 12 years)(Required)
Adolescents (12 years to 18 years)(Required)
Young Adults (18 years to 39 years)(Required)
Middle Adults (39 years to 64 years)(Required)
Older Adults (64 years to 79 years)(Required)
Elderly Adults (over 79+ years)(Required)

WORK SETTING

Home Hospice(Required)
Inpatient Hospice(Required)
Pediatric Hospice(Required)
Home Health/Hospice Setting(Required)

ASSESSMENT

Intake Assessment(Required)
Assessment Interview(Required)
Physical Exam(Required)
Coping Status(Required)
Environmental Status(Required)

PLAN OF CARE

Set Goals with Patient/Family(Required)
Collaborate with Other Team Members(Required)

SYMPTOM MANAGEMENT

Urgent Assessment of Symptoms(Required)
Reduce Symptoms to Level Acceptable to Patient(Required)
Report Symptoms/Management to Provider(Required)
Treat Underlying Cause(Required)
Severity Scale(Required)
Management of Nausea(Required)
Management of Constipation(Required)
Management of Fatigue(Required)
Anorexia/Cachexia(Required)
Restlessness(Required)
Educate Family of Symptom Management(Required)

PAIN MANAGEMENT

Identify Source of Pain(Required)
Pain Severity(Required)
PAINAD Scale for Non-verbal Patient(Required)
Reduce Pain to Level Acceptable to Patient(Required)
WHO 3-Step Ladder(Required)
Non-Pharmacological Management of Pain(Required)
Pharmacological Management of Pain(Required)
Effects of Pharmacological Treatment(Required)
Nociceptive/Neuropathic/Mixed Pain(Required)
Management of Nociceptive Pain(Required)
Management of Neuropathic Pain(Required)
Educate Family on Pain Management(Required)

WOUND CARE

Positioning Techniques(Required)
Bed/Support Surface Selection(Required)
Pressure Ulcer Staging/Management(Required)
Response to Treatment(Required)
Evaluate Factors that Impede Healing(Required)
Educate Family on Positioning/Shearing(Required)

PEDIATRICS

Developmentally Appropriate Assessment(Required)
Parental/Sibling Support(Required)
Pediatric Support Team Collaboration(Required)

MEDICATION ADMINISTRATION

Equianalgesic Conversion Formula(Required)
Titration of Opioids(Required)
IV Pump Management(Required)
Evaluate Effectiveness of Medications(Required)
Family Management of Medications(Required)
Disposal of Medications(Required)

AFTER DEATH

Family/Cultural Rituals/Rites(Required)
Patient Care after Death(Required)
Coordinate Mortuary Services(Required)
Bereavement Services(Required)

COMPLIANCE

Scope and Frequency of Services(Required)
Medicare/State Regulations for Hospice(Required)
Document Progression of Decline(Required)
DME Authorization & Documentation of Need/Order(Required)
OASIS-C(Required)

PROFESSIONAL KNOWLEDGE AND SKILLS

Identify Source of Suffering(Required)
Palliative Care Philosophy(Required)
Patient/Family Directs Goals of Care(Required)
Maximize Quality of Life(Required)
Cultural Diversity(Required)
Supervision of Ancillary Staff(Required)
National Patient Safety Goals/Core Measures(Required)
Fall Risk Assessment/Prevention(Required)
Infection Prevention(Required)
Isolation Precautions(Required)
Interpretation and Communication of Lab Values(Required)
Electronic Documentation
Automated Med Dispensing Systems

OTHER SKILLS

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