* = Required Information
Clinical Skills
Please use a check mark below
1 Move patient up in bed
Able to do Without Help
Unable to do
Plan of Action
RN Initial
2 Move patient toward you
Able to do Without Help
Unable to do
Plan of Action
RN Initial
3 Move patient away from you
Able to do Without Help
Unable to do
Plan of Action
RN Initial
4 Transfer patient to a wheelchair
Able to do Without Help
Unable to do
Plan of Action
RN Initial
5 Transfer techniques
Able to do Without Help
Unable to do
Plan of Action
RN Initial
6 Transport patient on wheelchair
Able to do Without Help
Unable to do
Plan of Action
RN Initial
7 Make an occupied bed
Able to do Without Help
Unable to do
Plan of Action
RN Initial
8 Make an unoccupied bed
Able to do Without Help
Unable to do
Plan of Action
RN Initial
9 Brush and clean patient mouth
Able to do Without Help
Unable to do
Plan of Action
RN Initial
10 Soak denture
Able to do Without Help
Unable to do
Plan of Action
RN Initial
11 Bed bath / sponge bath
Able to do Without Help
Unable to do
Plan of Action
RN Initial
12 Tub bath
Able to do Without Help
Unable to do
Plan of Action
RN Initial
13 Shower bath
Able to do Without Help
Unable to do
Plan of Action
RN Initial
14 Brush & comb patient hair
Able to do Without Help
Unable to do
Plan of Action
RN Initial
15 Shampoo patient hair
Able to do Without Help
Unable to do
Plan of Action
RN Initial
16 Give a bedpan
Able to do Without Help
Unable to do
Plan of Action
RN Initial
17 Foley catheter care
Able to do Without Help
Unable to do
Plan of Action
RN Initial
18 Change an ostomy bag
Able to do Without Help
Unable to do
Plan of Action
RN Initial
19 Assist patient with feeding
Able to do Without Help
Unable to do
Plan of Action
RN Initial
20 Perform Range- of- Motion – R.O.M
Able to do Without Help
Unable to do
Plan of Action
RN Initial
21 Assist patient to walk
Able to do Without Help
Unable to do
Plan of Action
RN Initial
22 Take oral temperature (mouth)
Able to do Without Help
Unable to do
Plan of Action
RN Initial
23 Take axillary temperature (armpit)
Able to do Without Help
Unable to do
Plan of Action
RN Initial
24 Count number f breath per minute
Able to do Without Help
Unable to do
Plan of Action
RN Initial
25 Blood Pressure: Read & Record
Able to do Without Help
Unable to do
Plan of Action
RN Initial
26 Skin care
Able to do Without Help
Unable to do
Plan of Action
RN Initial
27 Understand emergency procedures
Able to do Without Help
Unable to do
Plan of Action
RN Initial
28 Record daily duties performed for patient
Able to do Without Help
Unable to do
Plan of Action
RN Initial
29 Maintenance of clean & safe environment
Able to do Without Help
Unable to do
Plan of Action
RN Initial
** Note: Other skills will be added as needed by the delegating Nurse
Aide Name:
*
Date:
*
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