Hospice Checklist


Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Total Stars:

Obtained Stars:

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

  WORK SETTINGS         Rating Stars (Click) 1 2 3 4
  Home Hospice  
  Inpatient Hospice�  
  Pediatric Hospice  
  Home Health/Hospice Setting  
  ASSESSMENT         Rating Stars (Click) 1 2 3 4
  Intake Assessment�  
  Assessment Interview�  
  Physical Exam  
  Coping Status�  
  Environmental Status  
  PLAN OF CARE         Rating Stars (Click) 1 2 3 4
  Set Goals with Pt/Family�  
  Collaborate with Other Team Members�  
  Ensure Continuity of Care  
  SYMPTOM MANAGEMENT         Rating Stars (Click) 1 2 3 4
  Urgent Assessment of Symptoms�  
  Reduce Symptoms to Level Acceptable to Pt.�  
  Report Symptoms/Management to Provider�  
  Treat Underlying Cause�  
  Severity Scale�  
  Management of Nausea  
  Management of Constipation�  
  Management of Fatigue�  
  Anorexia/Cachexia�  
  Restlessness�  
  Educate Family on Symptom Management  
  PAIN MANAGEMENT         Rating Stars (Click) 1 2 3 4
  Identify Source of Pain�  
  Pain Severity�  
  PAINAD Scale for Non Verbal Patient�  
  Reduce Pain to Level Acceptable to Patient  
  WHO 3 Step Ladder�  
  Non-Pharmacologic Management of Pain�  
  Pharmacologic Management of Pain�  
  Effects of Pharmacologic Treatment�  
  Nociceptive/Neuropathic/Mixed Pain�  
  Management of Nociceptive Pain�  
  Management of Neuropathic Pain  
  Educate Family on Pain Management  
  WOUND CARE         Rating Stars (Click) 1 2 3 4
  Positioning Techniques�  
  Bed/Support Surface Selection�  
  Pressure Ulcer Staging/Management�  
  Response to Treatment�  
  Evaluate Factors that Impede Healing�  
  Educate Family on Positioning/Shearing  
  PEDIATRICS         Rating Stars (Click) 1 2 3 4
  Developmentally Appropriate Assessment�  
  Parental/Sibling Support�  
  Pediatric Support Team Collaboration  
  MEDICATION ADMIN         Rating Stars (Click) 1 2 3 4
  Equianalgesic Conversion Formula�  
  Titration of opioids�  
  IV Pump Management�  
  Evaluate Effectiveness of Medications�  
  Family Management of Medications�  
  Disposal of Medications  
  AFTER DEATH         Rating Stars (Click) 1 2 3 4
  Facility Family/Cultural Rituals/Rites�  
  Patient Care after Death�  
  Coordinate Mortuary Services�  
  Bereavement Services  
  COMPLIANCE         Rating Stars (Click) 1 2 3 4
  Scope and Frequency of Services�  
  Medicare/State Regulations for Hospice�  
  Document Progression of Decline�  
  DME Authorization & Documentation of Need/Order�  
  OASIS-C  
  PROFESSIONAL KNOWLEDGE AND SKILLS         Rating Stars (Click) 1 2 3 4
  Identify Source of Suffering�  
  Palliative Care Philosophy�  
  Patient/Family Directs Goals of Care�  
  Maximize Quality of Life�  
  Cultural Diversity  
  Supervision of Ancillary Staff  
  National Patient Safety Goals/Core Measures�  
  Fall Risk Assessment/Prevention  
  Infection Prevention�  
  Isolation Precautions�  
  Interpretation and Communication of Lab Values  
  EMR         Rating Stars (Click) 1 2 3 4
  Epic�  
  Cerner�  
  Eclipsys�  
  Allscripts�  
  McKesson  
  Meditech�  
  Other Computerized System�  
  Computerized Physician Order Entry�  
  Bar Coding for Medication Administration