Competency Orientation Module
Name of Role ie. Registered Nurse/Licensed Practical Nurse, Healthcare Tech, Surg Tech, etc
Module #: Name of Module–Name of Unit
Name: / Months of Orientation: / to

To be completed by Nurse Manager/Nurse Coordinator/Supervisor or RN Preceptor

  • Date and initial with the appropriate rating in the scale to show progress in meeting evaluation criteria.

Sign full name and initials on the separate signature page.

  • Please review this documentation by the end of each clinical orientation day. Current status should be evident at all times.
  • Upon completion, retain original copy for department file. Checklist to be sent to Human Resources after review with new employee during 3-month evaluation.
  • A Competency rating of ‘3’ must be achieved during the orientation process.

The orientee must show independence and consistency in all evaluation criteria listed.

Add comments to communicate information needed by other preceptors, the orientation coordinator or the manager.

The Orientee requires supervision for all items not yet evaluated with a competency rating of ‘3’.

N/A (not applicable) for this department can be indicated on form as needed.

Check the age specific abbreviation to the competency checklist where it applies. / Rating Scale for
Evaluation Progress
N = newborn (0-3m)
P = pediatric (3m-8y)
Adl = adolescent (9-17y) / A = adult (18-64y)
G = geriatric (>65y) / 1 = Needs more opportunity for development
2 = Demonstrates steady improvement
3 = Independent/competent/consistent
Competencies / Instruction Methods / Evaluation Criteria / Scale
  1. Name of the competency – should be written in goal/objective format.
/
  • What methods of instruction are you going to use to teach the orientee?
- Is it meeting with the manager?
- Is it a demonstration or role modeling or discussion with orientee?
  • What resources are available for the orientee to utilize to meet the competency expectation?
Is it reviewing a policy?
Is it meeting with a specific staff member?
  • Include critical thinking questions for the orientee to assist the preceptor.
/
  • What is the behavior or knowledge or skill that you want the orientee to exhibit before they are competent?
  • If it is knowledge, then is verbalization of that knowledge enough to be competent or do they review information and then pass a quiz on that information?
  • Include evidence of competency examples.
/ 1 / 2 / 3
Comments

Examples:

Competencies / Instruction Methods / Evaluation Criteria / Scale
Demonstrates integration of hospital and nursing mission and values into practice. /
  • Discuss and role model Carle mission and values.
  • Discuss and role model nursing mission and values.
/
  • Observe evidence of daily practice for interactions with patients, visitors and other health care professionals for consistency with hospital and nursing mission and values.
  • Evidence examples:
-Greets staff, patients, and families with respect, warmth and genuineness
-Calls the patient by his or her preferred name
-Display proper phone etiquette
-Anticipates patient and family anxiety and offer information, reassurance, and comfort as appropriate.
-Works cooperatively with team members
  • Orientee locates mission and values (nursing) on Cweb.
/ 1 / 2 / 3
Comments
Competencies / Instruction Methods / Evaluation Criteria / Scale
Recognizes/responds to signs/symptoms of abuse. /
  • View “Identifying Victims of Abuse” video on Learner-in-Charge. Reference Lippincott manual and search “elder abuse” for a table on identifying abuse and neglect.
  • Reference policies:
- RI104 Domestic Violence
-RI105Mandatory Reporting of Suspected Child Abuse/Neglect,
-RI208Elder Abuse/Neglect,
-RI103 Alleged Sexual Assault Survivors
-Preservation of Evidence-EC623
Critical thinking
  • What are the signs/ symptoms of abuse that you are going to be looking for during your assessment?
  • What type of behavior might you notice from family members?
  • What type of behavior might you notice from the patient?
  • Who is your best resource for discussing the patient issue with?
/
  • Observe Orientee assessing for, identifying and responding to actual signs and symptoms of abuse
OR
  • Ask Orientee to describe signs and symptoms of abuse in unit-specific context and how to report/intervene.
N P Adl A G / 1 / 2 / 3
Comments:
References
Children’s Hospitals and Clinics Minneapolis and St. Paul, MN. Incident Reporting and Management Policy.
The Dana –Farber Cancer Institute Boston, MA. Policy for Disclosing Medical Errors to Patients and Families
Joint Commission Accreditation of Healthcare Organization Oakbrook Terrance, IL.

Maintain in Unit Education File