Self-Assessment Of Clinical Skills

I work in an area that is consistent with my licensure, specialty certification, training and experience.

I know that my competencies – including experience, training, education and skills – are consistent with the needs of my patients. Self-Assessment Of Clinical Skills

I understand the specific risks of caring for patients within my clinical specialty.

I decline an assignment if my competencies are not consistent with patient needs.

I ensure that my competencies and experience are appropriate before accepting an assignment to cover for another practitioner.

I am provided with orientation, or request and obtain it, whenever I work in a new or different clinical setting.

I obtain continuing education and training, as needed, to maintain my competencies in my clinical specialty.

Scope of practice and scope of services

I read my state nurse practice act at least once per year to ensure that I understand and am in compliance with the legal scope of practice in my state. Self-Assessment Of Clinical Skills

I know and comply with the requirements of my state regarding physician collaborative or supervisory agreements, and I review and renew my agree- ments at least annually.

I comply with the requirements of my state regarding other regulatory bodies, such as the board of medicine (if applicable).

I collaborate with or obtain supervision from a physician as defined by my state laws and/or regulations and as required by the needs of my patients. Self-Assessment Of Clinical Skills

I seek alternative physician consultation if I am not provided with appro- priate support from my collaborating/supervising/employing physician(s), and modify my agreements accordingly.

I decline to perform requested actions/services if they are outside of my legal scope of practice.

Assessment

I elicit the patient’s concerns and reasons for the visit and address those concerns.

I obtain and document a current list of the patient’s prescribed and over- the-counter medications, including nutritional supplements and holistic/ alternative remedies. Self-Assessment Of Clinical Skills

I document any patient allergies and adverse reactions to medications.

I gather, document and utilize an appropriate patient clinical history, as well as relevant social and family history.

I ascertain the patient’s level of compliance with currently ordered treatment and care instructions, medication regimens and lifestyle suggestions.

I perform a physical examination to determine the patient’s health status and evaluate the patient’s current symptoms/complaints.

I determine if the patient’s current health status requires immediate medical treatment, and refer the patient to an emergency department if needed.

I adhere to facility documentation requirements regarding assessment findings.

CNA ANd NSO Risk ContRol self-assessment CheCklist foR nuRse PRaCtitioneRs 2

Self-assessment topic Yes No Actions needed to reduce risks

Diagnosis

I utilize an objective, evidence-based approach, applying organization- approved clinical guidelines and standards of care to timely and accurately determine the patient’s differential diagnosis. Self-Assessment Of Clinical Skills

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I consider the findings of the patient’s assessment, history and physical examination, as well as the patient’s expressed concerns, in establishing the diagnosis, and document my findings.

I order and timely obtain results of appropriate diagnostic testing – including laboratory analysis, radiography, EKG, etc. – before determining the diagnosis, and document ordered tests and results.

I consult with my collaborating/supervising physician, as required, to estab- lish the diagnosis and treatment plan, and document all such encounters. Self-Assessment Of Clinical Skills

I request, facilitate and obtain other appropriate consultations, as necessary, to achieve a timely and correct diagnosis.

When establishing the diagnosis, I comply with the standard of care, as well as my facility’s policies, procedures, and clinical and documentation protocols.

If a patient is unstable, acutely ill and in need of immediate diagnostic testing and/or consultation, I refer him or her to hospital emergency care and facilitate this process, if necessary.

If a diagnostic test or procedure involves risk, I conduct and document an informed consent discussion with the patient and obtain the patient’s witnessed consent.

I proactively gather, document and respond to the results of diagnostic tests/procedures and provide necessary orders.

I obtain, document and respond to the results of diagnostic consultations with physicians and other healthcare providers.

I establish the diagnosis, determine a treatment plan, document clinical decision-making, and order and implement the treatment and care plan. Self-Assessment Of Clinical Skills

I discuss clinical findings, diagnostic test/procedure results, consultant find- ings, diagnosis, the proposed treatment plan and reasonable expectations for a desired outcome with patients, in order to ensure their understanding of their care or treatment responsibilities. I document this process, noting the patient’s response.

I counsel the patient regarding the risks of not complying with diagnostic testing, treatment and consultation recommendations, and document discussions. If recurrent noncompliance is potentially affecting the safety of the patient and regular counseling has been ineffective, I consider dis- charging the patient from the practice. Self-Assessment Of Clinical Skills

If the patient is uninsured or unable to afford necessary diagnostic and consultative procedures, I refer him or her for financial assistance, pay- ment counseling, and/or free or low-cost alternatives, and document these actions.

If I work in a state with autonomous nurse practitioner authority, I regularly seek peer review to assess my diagnostic skills and expertise and to identify opportunities for improvement.

CNA ANd NSO Risk ContRol self-assessment CheCklist foR nuRse PRaCtitioneRs 3

Self-assessment topic Yes No Actions needed to reduce risks

Treatment and care

I educate the patient regarding the diagnosis, treatment plan, and need for compliance with treatment recommendations, medication regimens and screening procedures. I document the discussion.

I prescribe clinically indicated treatment and care and provide appropriate health screening for the patient.

I discuss the patient’s treatment plan and ongoing response to treatment with my collaborating/supervising physician as required and appropriate, and document the interaction.

I discuss with the patient and document any deviation from established protocols, guidelines or standards, and explain the clinical rationale for the alternative plan.

I advise the patient to obtain emergency medical treatment in the event of unexpected adverse symptoms or effects of treatment, and document the discussion.

I conduct and document an informed consent discussion with the patient prior to implementing any aspect of the treatment plan that involves potential risk, ask the patient to repeat the main points of the discussion, and obtain the patient’s stated and written consent.

I perform regular monitoring tests and consultation, as needed, to appro- priately manage the patient’s healthcare, and document all findings. Self-Assessment Of Clinical Skills

I inform the patient of test and consultation results, both normal and abnormal, and document the discussion.

I schedule follow-up visits to monitor the patient’s response to treatment, and I adjust the patient’s treatment plan as needed and appropriate.

I remind patients of regular appointments and screening tests, and document these reminders.

I contact patients after missed appointments for rescheduling, and document these contacts.

I counsel patients regarding their treatment plan responsibilities and the need for compliance with ongoing testing, medication regimens and life- style choices that potentially affect outcomes, ensure their ability to repeat the information correctly, and document these interactions Self-Assessment Of Clinical Skills

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