Hospice LPN

1 = No theory and/or experience 2 = Limited Experience 3 = Experienced/minimal support needed to perform 4 = Proficient

Age of Patients Cared For
Newborn/Neonate (birth – 30 days)*
- 1
- 2
- 3
- 4
Infant (1 month to 1 year)*
- 1
- 2
- 3
- 4
Toddler (1 year to 3 years)*
- 1
- 2
- 3
- 4
Preschooler (3 years to 5 years)*
- 1
- 2
- 3
- 4
School Age Child (5 years to 12 years)*
- 1
- 2
- 3
- 4
Adolescents (12 years to 18 years)*
- 1
- 2
- 3
- 4
Young Adults (18 years to 39 years)*
- 1
- 2
- 3
- 4
Middle Adults (39 years to 64 years)*
- 1
- 2
- 3
- 4
Older Adults (64 years to 79 years)*
- 1
- 2
- 3
- 4
Elderly Adults (over 79+ years)*
- 1
- 2
- 3
- 4
Work Setting
Home Hospice*
- 1
- 2
- 3
- 4
Pediatric Hospice*
- 1
- 2
- 3
- 4
Inpatient Hospice*
- 1
- 2
- 3
- 4
Home Health/Hospice Setting*
- 1
- 2
- 3
- 4
Assessment
Intake Assessment*
- 1
- 2
- 3
- 4
Assessment Interview*
- 1
- 2
- 3
- 4
Physical Exam*
- 1
- 2
- 3
- 4
Coping Status*
- 1
- 2
- 3
- 4
Environmental Status*
- 1
- 2
- 3
- 4
Plan of Care
Set Goals with Patient/Family*
- 1
- 2
- 3
- 4
Collaborate with Other Team Members*
- 1
- 2
- 3
- 4
Symptom Management
Urgent Assessment of Symptoms*
- 1
- 2
- 3
- 4
Reduce Symptoms to Level Acceptable to Patient*
- 1
- 2
- 3
- 4
Report Symptoms/Management to Provider*
- 1
- 2
- 3
- 4
Treat Underlying Cause*
- 1
- 2
- 3
- 4
Severity Scale*
- 1
- 2
- 3
- 4
Management of Nausea*
- 1
- 2
- 3
- 4
Management of Constipation*
- 1
- 2
- 3
- 4
Management of Fatigue*
- 1
- 2
- 3
- 4
Anorexia/Cachexia*
- 1
- 2
- 3
- 4
Restlessness*
- 1
- 2
- 3
- 4
Educate Family of Symptom Management*
- 1
- 2
- 3
- 4
Pain Management
Identify Source of Pain*
- 1
- 2
- 3
- 4
Pain Severity*
- 1
- 2
- 3
- 4
PAINAD Scale for Non-verbal Patient*
- 1
- 2
- 3
- 4
Reduce Pain to Level Acceptable to Patient*
- 1
- 2
- 3
- 4
WHO 3-Step Ladder*
- 1
- 2
- 3
- 4
Non-Pharmacological Management of Pain*
- 1
- 2
- 3
- 4
Pharmacological Management of Pain*
- 1
- 2
- 3
- 4
Effects of Pharmacological Treatment*
- 1
- 2
- 3
- 4
Nociceptive/Neuropathic/Mixed Pain*
- 1
- 2
- 3
- 4
Management of Nociceptive Pain*
- 1
- 2
- 3
- 4
Management of Neuropathic Pain*
- 1
- 2
- 3
- 4
Educate Family on Pain Management*
- 1
- 2
- 3
- 4
Wound Care
Positioning Techniques*
- 1
- 2
- 3
- 4
Bed/Support Surface Selection*
- 1
- 2
- 3
- 4
Pressure Ulcer Staging/Management*
- 1
- 2
- 3
- 4
Response to Treatment*
- 1
- 2
- 3
- 4
Evaluate Factors that Impede Healing*
- 1
- 2
- 3
- 4
Educate Family on Positioning/Shearing*
- 1
- 2
- 3
- 4
Pediatrics
Developmentally Appropriate Assessment*
- 1
- 2
- 3
- 4
Parental/Sibling Support*
- 1
- 2
- 3
- 4
Pediatric Support Team Collaboration*
- 1
- 2
- 3
- 4
Medication Administration
Equianalgesic Conversion Formula*
- 1
- 2
- 3
- 4
Titration of Opioids*
- 1
- 2
- 3
- 4
IV Pump Management*
- 1
- 2
- 3
- 4
Evaluate Effectiveness of Medications*
- 1
- 2
- 3
- 4
Family Management of Medications*
- 1
- 2
- 3
- 4
Disposal of Medications*
- 1
- 2
- 3
- 4
After Death
Family/Cultural Rituals/Rites*
- 1
- 2
- 3
- 4
Patient Care after Death*
- 1
- 2
- 3
- 4
Coordinate Mortuary Services*
- 1
- 2
- 3
- 4
Bereavement Services*
- 1
- 2
- 3
- 4
Compliance
Scope and Frequency of Services*
- 1
- 2
- 3
- 4
Medicare/State Regulations for Hospice*
- 1
- 2
- 3
- 4
Document Progression of Decline*
- 1
- 2
- 3
- 4
DME Authorization & Documentation of Need/Order*
- 1
- 2
- 3
- 4
OASIS-C*
- 1
- 2
- 3
- 4
Professional Knowledge and Skills
Identify Source of Suffering*
- 1
- 2
- 3
- 4
Palliative Care Philosophy*
- 1
- 2
- 3
- 4
Patient/Family Directs Goals of Care*
- 1
- 2
- 3
- 4
Maximize Quality of Life*
- 1
- 2
- 3
- 4
Cultural Diversity*
- 1
- 2
- 3
- 4
Supervision of Ancillary Staff*
- 1
- 2
- 3
- 4
National Patient Safety Goals/Core Measures*
- 1
- 2
- 3
- 4
Fall Risk Assessment/Prevention*
- 1
- 2
- 3
- 4
Infection Prevention*
- 1
- 2
- 3
- 4
Isolation Precautions*
- 1
- 2
- 3
- 4
Interpretation and Communication of Lab Values*
- 1
- 2
- 3
- 4
Please list the EMR systems you have used*
*
I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form.*
*
I hereby consent to allow CrossMed Healthcare Staffing Solutions to release these skills checklist to the client facilities.*
Your Recruiter*
Name*
First Last
Email*
Phone*
TODAY'S DATE*
MM slash DD slash YYYY