Staff Name

Competency Employee No.

Checklist Ward
Position

Title: CARE OF PATIENT IN PACU Observed under supervision

1 2 3 4 5
Date
Preceptors signature
Preceptors Name/GHS
Preceptors Position
Rating Scale:
1 Poor = Unable to demonstrate or perform.
2 Fair = Demonstrate / performs safely with close guidance and supervision.
3 Satisfactory = Demonstrate adequate knowledge / skills. Able to perform with minimal guidance / supervision.
4 Good = Performs independently and safely without guidance and / or supervision.
5 Excellent = Consistently performs independently and safely without guidance and / or supervision. Able to
instruct, teach and mentor new nurses.
Date: Date: Date: Date: Date:
No. Procedure steps description
Rating Rating Rating Rating Rating
CRITICAL BEHAVIOUR
1 Maintenance of clear airway :
-insertion of correct size airway
-removal of airway
2 Administration of O2 , if ordered by
Anesthetist
3 Warming up patient
4 Initial monitoring:
- B/P
- pulse oxymeter
- ECG monitoring if necessary
- suction prn
- care of I/V line
- care of wound dressing
- care of drainage
- circulation ( color and sensation of
extremities )
- check by bleeding for O&G cases
5 Record and dispatch of specimens
6 Documentation:
- assessment of patient
- monitoring of vital signs
- nursing interventions and evaluation
- report to ward nurse
- specimens

Total Rating / / / / /
Competency Level (%)
Assessor Signature
Assessor Name/GHs
Assessor Position
 Competent Level Description
>80% Competent. Able to perform without supervision.
51% - 79% Need supervision. Required reassessment after 2 weeks.
<50% Required coaching and supervision. Reassessment after 4 weeks.

Assessors Comment

Declaration of Competence

We hereby declare that RN _____________________________________________ is competent to perform the

above named procedure.

Verified by NM / ANM: Verified by Nurse Educator / CRN:

Signature: Signature:
Date: Date:
Competency reference: AORN