Skills Competency Assessment FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4NameDate OrientationAnnualOther ** Level of Experience ** A. Theory, no practice C. One - Two years experience B. Intermittent experience D. Two plus years experience ** Evaluation Method ** 1. Direct Observation 2. Simulation 3. Verbalization 4. Documentation Self Assessment (Level of Experience) Competency for the PERSONAL CARE ASSISTANT (PCA) Evaluation Method Competency Validation Indicated by Supervisor’s Initials and Date ABCDDemonstrates ability to process paperwork and associated functions necessary to facilitate: 1234 ABCD1. Bed bath 1234 ABCD2. Shower/tub bath 1234 ABCD3. Nail care 1234 ABCD4. Skin care 1234 ABCD5. Oral care 1234 ABCD6. Shampoo 1234 ABCD7. Toileting/Elimination 1234 ABCDa. Urinal 1234 ABCDb. Bedpan 1234 ABCDc. Other 1234 ABCD8. Transfer techniques: 1234 ABCDa. Bed to chair 1234 ABCDb. Chair to standing 1234 ABCDc. Assist with ambulation 1234 ABCDd. Other 1234 ABCD9. Assists with exercise program range of motion 1234 ABCD10. Assistive devices: 1234 ABCDa. Walker 1234 ABCDb. Cane 1234 ABCDc. Ensures participant access to needed and available community resources coordinating supports across agencies 1234 ABCDd. Participates in outreach to potential participants 1234 ABCDe. Other 1234 NextSelf Assessment (Level of Experience) Competency for the PERSONAL CARE ASSISTANT (PCA) Evaluation Method Competency Validation Indicated by Supervisor’s Initials and Date ABCD11. Positioning 1234 ABCD12. Optional Skills: 1234 ABCDa. Dry dressings 1234 ABCDb. Ace bandage wrap 1234 ABCDc. Medication reminders 1234 ABCD13. Documentation Skills: (legible, timely, accurate and complete) 1234 ABCDa. Progress notes 1234 ABCDb. Incident reporting 1234 ABCDc. Relates to POC 1234 ABCDd. Other 1234 ABCD14. Observation and reporting to: 1234 ABCDa. Other professional 1234 ABCDb. Other 1234 ABCD15. Adheres to POC 1234 ABCDa. Reviews POC prior to care 1234 ABCDb. Performs services as ordered 1234 ABCDc. Documents according to POC 1234 ABCDd. Communicates/coordinates if appropriate 1234 ABCDe. Other 1234 PreviousNextSelf Assessment (Level of Experience) Competency for the PERSONAL CARE ASSISTANT (PCA) Evaluation Method Competency Validation Indicated by Supervisor’s Initials and Date ABCD16. Infection Control 1234 ABCDc. Exposure plan 1234 ABCDd. Other 1234 ABCD17. Emergency procedures 1234 ABCD18. Submits written summary reports as required 1234 ABCD19. Attends case conference as required 1234 ABCD20. Client/Patient safety/falls risk 1234 ABCD21. Meal preparation: 1234 ABCDa. Feeding 1234 ABCDb. Diabetic diet 1234 ABCDc. Low sodium 1234 ABCDd. Low cholesterol/fat 1234 ABCD22. Light housekeeping 1234 ABCD23. Linen change/wash clothing 1234 ABCD24. Other 1234 PreviousNextSelf Assessment Evaluation: Proficient (Deemed Knowledgeable)Limited Experience (Needs Further Education and Orientation)No Experience (Needs One-on-One Education / Orientation and Shadowing Peer)Identified Deficiencies: Action Plans: Desired Outcome and Time Frame: Action if outcome NOT met: Full Name Clear DateAgency Rep. Full NameDatePreviousSubmit
