Clement J. Zablocki Medical Center

5000 West National Ave.

Milwaukee, Wisconsin 53295

Student Nurse Tech – Checklist for Clinical Experience

To the faculty of ______School of Nursing:

Your student ______has applied for a Student Nurse Tech (SNT) position at the Zablock VA Medical Center. It is the VA policy on Student Nurse Techs they may only perform nursing procedures they have successfully completed through an approved course of instruction with return demonstration at their school of training. To assure accuracy of clinical competence and make the best possible placement for the student we require them to complete the following checklist. Please review their self-assessment of their clinical practice abilities and sign below to indicate your acknowledgement f its accuracy. Prospective employees must have this form complete before they begin the interview process. Your assistance is appreciated.

Clinical Skill

/ Students assessment – initial below each skill you can perform independently- having had experience in clinical settings / Instructor assessment- initial below to concur with students self assessment of competency / Preceptor assessment – initial below to concur with students self assessment of competency
(To be filled in by preceptor- after employment)
Utilizes Standard Precautions
Identifies categories of isolation
Gathers and documents diagnostic measurement data including:
  • TPR
  • Blood Pressure
  • Weight

Blood Glucose Testing
Measures Pulse Oximetry
Measures and records I&O
Provides Activities of Daily Living (ADLs):
  • Feeding patients
  • Bathing (bed and shower)
  • Oral hygiene
  • Hair Care

Continued on back of page

Clinical Skill

/ Students assessment – initial below each skill you can perform independently- having had experience in clinical settings / Instructor assessment- initial below to concur with students self assessment of competency / Preceptor assessment – initial below to concur with students self assessment of competency
(To be filled in by preceptor- after employment)
Insertion of NG tubes –
  • Salem Sump
  • Levin
  • Feeding

Removal of above tubes-
Insertion of urinary catheters-
  • Foley
  • Intermittent Cath

Removal of urinary catheters
Application of external urinary devices
Collects specimens-
  • Sputum
  • Stool
  • Urine

Administration of oxygen
Tracheal Bronchial Toileting
  • Oral suction
  • Nasal suction

Tracheostomy care
Postural Drainage
Chest Clapping
Dressing changes
  • Sterile
  • Non-sterile

Application of moist heat
Colostomy care
Bowel Routines (bowel stimulation for spinal cord injury patients)
Other skills not listed: (may use another sheet if necessary)

I confirm ______has successfully completed the initialed clinical skills during her training at our institution.

Signature of Instructor: ______date: ______

Signature of Student: ______date: ______

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