Your name
Your Email
Last 4 Of SSN
Date
E-Signature
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.
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.
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Preparation
Introduces self to patient and explains blood tests have been ordered by physician: 0★★★★−
Identifies the patient with two unique identifiers (armband, ask for name & DOB). Compare patient ID information with barcode label: 0★★★★−
Checks testing requirements (ie fasting): 0★★★★−
Prepares supplies and tube selection: 0★★★★−
Washes hand, dons gloves: 0★★★★−
Getting Started
Positions Patient and applies tourniquet: 0★★★★−
Palpates antecubital area to select venipuncture site: 0★★★★−
Properly cleanses venipuncture site: 0★★★★−
Sample Collection
Stabilizes vein: 0★★★★−
Inserts needle, bevel up: 0★★★★−
Smoothly pushes tube(s) into holder without changing needle position: 0★★★★−
Adjusts needle, if necessary, to obtain flow then stabilizes vacutainer: 0★★★★−
Releases tourniquet as blood begins to flow: 0★★★★−
Changes vacutubes without changing needle position: 0★★★★−
Fills vacutubes in correct order: 0★★★★−
Mixes anticoagulated vacutubes properly: 0★★★★−
Removes last tube from needle before withdrawing needle: 0★★★★−
Withdraws needle from arm smoothly: 0★★★★−
Applies pressure to site after withdrawing needle: 0★★★★−
Disposes of needle properly and safely, Discards tourniquet: 0★★★★−
Handling & Processing
Labels tubes immediately (ie at bedside): 0★★★★−
Legibly completes label/requisition with username and date/time of collection: 0★★★★−
Observe special handling requirements: 0★★★★−
Checks puncture site to ascertain bleeding has stopped. Applies bandage: 0★★★★−
Places tubes into biohazard bag. Label(s)/requisition are placed in sleeve of bag: 0★★★★−
Removes gloves and practice hand hygiene: 0★★★★−
Transport specimens to lab via porter or pneumatic tube system. STATs are sent immediately: 0★★★★−
Age Specific Competencies
Infant (Birth - 1 year): 0★★★★−
Preschooler (ages 2-5 years): 0★★★★−
Childhood (ages 6-12 years): 0★★★★−
Adolescents (ages 13-21 years): 0★★★★−
Young Adults (ages 22-39 years): 0★★★★−
Adults (ages 40-64 years): 0★★★★−
Older Adults (ages 65-79 years): 0★★★★−
Elderly (ages 80+ years): 0★★★★−
Certifications
Resource location – Lab Test information Guide Expiry Date:
Blood Culture Collection Review. Expiry Date:
Blood Ethanol Collection – cleanse site with soap and water Expiry Date:
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