Cardiac Rehab RN Competency - St. Mary's Medical Center

St. Mary’s Medical CenterCompetency AssessmentJob Title: _Registered Nurse/ Exercise Physiologist Dept.: _Cardiopulmonary Rehab InstituteTime Frame __August 1, 2012___________ through __April 15, 2013__________Employee Name_____________________________ Employee ID#: .This form is to be completed by the employee. For each of the competency statement listed below, theemployee may select which method of verification he or she would like to use for validation of his orher skill in that area. See separate forms on the intranet for details on each specific method ofverification requirements. The form indicated for a selected method of verification must be used. Inaddition, some competencies must be completed by a certain deadline in order to use. When allcompetencies are completed, make a copy of this form and all supporting forms for your records andsubmit the original to your unit Director. You do not have to wait until April 15 th to submitdocumentation, but all must be done. Refer to your Staff Development Specialist and/or Director forquestions.You only need to select one verification method for each competencyCompetencyLeadershipSkills:Accountability/ProfessionalismMethod of Verification Exemplar: Active participant on a project through aunit or hospital-wide council, committee, orProfessional Organization.Exemplar: Write an exemplar of how you handled ordefused a situation or an issue, giving feedback orholding someone accountable to a practice standard.Validation FormForm AP1Form AP2 Presentation (must be completed by January 15,2013):Do a presentation or video addressing a topic related toaccountability or professionalism.Group Discussion: Actively participates in a planneddiscussion group regarding accountability and/orprofessionalism.Evidence of Daily Work: Primary Preceptor for RN,NR, PCT, or UAForm AP3______________Signature of SDSForm AP4Form AP5______________Signature of SDSHumanCaring &RelationshipSkills:RelationshipBased Care/CARINGBehaviorsDiscussion Group: Discuss the use of RBC to improveHCAHPS scores.Discussion Group/Reflection: Discuss use of RBCand CARING Behaviors with a difficult patient and/orfamily member.Exemplar: Write an exemplar regarding BuildingBridges with others.Form RBC1Form RBC2Form RBC3Daily Work: Submit evidence of in-corporating RBCand CARING Behaviors into daily work.Form RBC 4

St. Mary’s Medical CenterCompetency AssessmentJob Title: _Registered Nurse/ Exercise Physiologist Dept.: _Cardiopulmonary Rehab InstituteTime Frame __August 1, 2012___________ through __April 15, 2013__________Employee Name_____________________________ Employee ID#: .CompetencyTeachingskills:Cardiac riskfactoreducationTeachingSkills:PulmonaryBreathingtechniqueeducationCriticalthinking skills:Response toCode BlueKnowledgeIntegrationSkills: EKGInterpretationMethod of Verification Daily work: Documentation for education on the riskfactor sheet with 3 patients at either the entrance or exitinterview. Presentation: Provide an in-service to staff discussingcurrent evidence regarding education about cardiac riskfactors. Must be pre-approved by January 1, 2013 byStaff Development Specialist.Pre-approval signature/date:________________Timeframe for education to occur:___________ Discussion: Participate in a discussion group thatdiscusses cardiac risk factor education. Daily Work: Documentation on Breathing techniqueeducation for one patient Exemplars: Write an exemplar describing the impacteducation on breathing techniques impacted a patientattending pulmonary rehab. Presentation: Provide an in-service to staff discussingcurrent evidence regarding education on breathingtechniques. Must be pre-approved by January 1, 2013by Staff Development Specialist.Pre-approval signature/date:________________Timeframe for education to occur:___________ Mock scenario: Particpate in Mock CODE BLUEwithin Cardiac Rehab Department Demonstration: Check off during NSED Case Study: Present a case study about the response toa cardiac or pulmonary arrest. Test: Review six 12 Lead EKGs provided in theCompetency Resources and accurately interpret. Case Study: Present a case study for a patient that hasserial EKG changes and lead the discussion about whythe changes occurred.Validation FormDocumentationIn-serviceevaluationsummaryForm CRFE 1DocumentationForm PBTE 1In-serviceevaluationsummaryMock Code BlueReportForm RCB 1Form RCB 2AHU transcriptForm EKGI 1

St. Mary’s Medical CenterCompetency AssessmentJob Title: _Registered Nurse/ Exercise Physiologist Dept.: _Cardiopulmonary Rehab InstituteTime Frame __August 1, 2012___________ through __April 15, 2013__________Employee Name_____________________________ Employee ID#: .CompetencyMethod of VerificationValidation Form Presentation: Provide an in-service about EKGs andinterpretation. Must be pre-approved by January 1, 2013by Staff Development Specialist.Pre-approval signature/date:________________Timeframe for education to occur:___________In-serviceevaluationsummaryEducation andOtherrequirementsBLS Attach copy of card BLS cardACLS Attach copy of card ACLS cardCardiacCompetencyTestPulmonaryCompetencyTest Attach passing test Attach passing testWith consideration of the employee’s performance and competency assessment, this employee iscompetent to perform as a(n):__________________ on/in___________________ □ Yes □ No (not yet deemed competent)Job titleUnit/DeptAction PlanEmployee Signature_____________________________ Date____________Director Signature______________________________Date____________