SKILLS LABORATORY CHECKLIST

Name Date
Course & Sec RLE Group

SETTING UP
Correctly Incorrectly Not
Steps Remarks
Done Done Done
Note:
 Always wear gloves when doing any
venipuncture.
1. Verify the written prescription of the doctor
2. Observe the twelve (12) Rights of medication
administration
3. Explain procedure to reassure patient and/or
significant other
4. Secure consent from the patient of guardian.
5. Choose appropriate site, location, size and
condition of the vein.
6. Prepare necessary materials for the procedure.
7. Check the integrity of the IV solution, IV set and
other devices.
8. Place IV label on IVF bottle duly signed by IV
Therapy Nurse RN who prepared it.
9. Do hand hygiene before and after the procedure.
10. Wear gloves only during venipuncture.
11. Open IV administration set aseptically, close the
roller clamp, and spike the infusate container
aseptically following the infection control
measures.
12. Fill drip chamber to at least half and prime it with
IV fluid aseptically.
13. Expel air bubbles if any and put back the cover to
the distal end of the IV set.

Grade:
Rating Scale:

Excellent : 96-100 Good : 80-84

Very Satisfactory : 90-95 Fair : 75-79
Very Good : 85-89 Poor : 74 & below
Clinical Instructor

Signature over Printed Name

 SKILLS LABORATORY CHECKLIST

Name Date
Course & Sec RLE Group

CHANGING AN IV SOLUTION
Correctly Incorrectly Not
Steps Remarks
Done Done Done
1. Observe 12 Rs.
2. Verify doctor's prescription.
3. Explain procedure to the patient.
4. Change IV tubing and cannula per hospital policy.
5. Wash hands before and after.
6. Prepare necessary materials.
7. Check integrity of the IV solution.
8. Place IV label on the IV bottle.
9. Calibrate new IV bottle according to duration of
infusion. as per prescription.
10. Open and connect the IV. tubing into the solution
bottle.
11. Regulate the flow rate according to the prescribed
infusion rate. Expel air bubbles, if evident.
12. Discard all waste materials according to Health
Care Waste Management (DOH/DENR).
13. Document and hand-off accordingly.

Grade:

Rating Scale:

Excellent : 96-100 Good : 80-84

Very Satisfactory : 90-95 Fair : 75-79
Very Good : 85-89 Poor : 74 & below

Clinical Instructor

Signature over Printed Name

 SKILLS LABORATORY CHECKLIST

Name Date
Course & Sec RLE Group

DISCONTINUING AN IV INFUSION
Correctly Incorrectly Not
Steps Remarks
Done Done Done
1. Verify written doctor's prescription.
2. Observe 12 Rights of Medication.
3. Explain procedure to the patient.
4. Prepare the necessary materials.
5. Wash hands before and after procedure.
6. Close the roller clamp of the IV administration set.
7. Remove tapes utilizing appropriate techniques.
8. Inspect IV catheter for completeness.
9. Place dressing over the venipuncture site.
10. Discard all waste materials including the IV
cannula according to Health Care Waste
Management (DOH/ DENR).
11. Document time of discontinuance, status of
insertion site and integrity of IV catheter and
hand-off accordingly.

Grade:

Rating Scale:

Excellent : 96-100 Good : 80-84

Very Satisfactory : 90-95 Fair : 75-79
Very Good : 85-89 Poor : 74 & below

Clinical Instructor

Signature over Printed Name