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RN Competency Form: Generalist
Competence Verification & Learning Guide: Facility
Name (learner)
Date Initiated
Unit
☐RN  ☐LPN  ☐Recent Graduate  ☐Experienced Nurse  ☐New to Specialty  ☐Traveling Nurse 
Note: for LPN practice guidelines, see state nursing statutes & regulations
The preceptor will initial each competency when he/she, as preceptor and colleague, feels safe in allowing the learner to deliver this aspect of care
without direct supervision.
Self-Assessment: 1 – Identified Limitation (little or no experience); 2 – Capable (familiar but may need assistance); 3 – Independent - can
perform these tasks safely; 4 – Proficient - extensive experience *For further information, see instruction sheet at end of this form.
References
IA. The learner will incorporate relevant assessment & intervention (A&I) skills in delivery of care to include the following:
Initiate life-saving/emergency measures consistent with
patient needs and protocols
Learning Guide #
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Preceptor initials
Verification method
& facility specific requirements
Learner initials
Required Competencies
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Date all met
Self-assessment
Learning Guide follows competency pages and contains items for each competency that need to be reviewed based on learner’s experience and unit
need, they include reminders of important teaching points that may otherwise be missed.
IA 1
Conduct initial assessment to identify patient’s needs
and priorities of care (full physical assessment--RN only,
LPN’s may perform limited, targeted assessments)
IA 2
Develop individualized plan of care that reflects current
practice standards (RN only)
IA 3
Implement plan of care based on patient-related data
and best practices
IA 4
Integrate developmental and age specific needs in
approach to and delivery of care
IA 5
Use equipment based on age, weight and need
IA 6
Implement measures and precautions to insure patient
safety and well-being
IA 7
Complete restraint competencies
as required.
Promote increase in client independence
teach/assist patients with PT/OT/ST per protocols
maximize client decision making
IA 8
Implement mental health & alcohol/substance abuse
behavior protocols
IA 9
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 1
References
Learning Guide #
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Preceptor initials
Verification method
& facility specific requirements
Learner initials
Required Competencies
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Date all met
Self-assessment
RN Competency Form: Generalist
Manage patient on cardiac monitor
place leads correctly
interpret rhythm correctly
intervene as needed
IA 10
Manage nutritional support - recognize need
manage tube feedings per protocol
administer total parenteral nutrition per protocol
IA 11
IB. The learner will incorporate relevant A & I skills in delivery of medications, IV’s & blood to include the following:
Administer medication to assigned patients
implement safe practice with high risk medication
complete procedural sedation
implement the “rights” of med administration
competency if req’d
state indications, contra-indications and side effects
(may use reference)
administer IVPB solution
administer IV push/bolus med (RN only)
Manage peripheral IV care consistent with protocols
verbalize pediatric and geriatric volume and dosage
precautions
Manage central/PICC line consistent with protocols
use correct flush solution and technique
apply policy for clotted line
assess site for complications
NOTE: LPN’s limited to specific training per state regs
Administer blood/blood products (RN only) per protocol
IB 1
IB 2
IB 3
complete PICC competency if
required
Perform venipuncture on an adult &/or child or infant
heel stick as applicable
IC. The learner will incorporate relevant A & I skills in performing procedures & utilizing equipment to include:
Integrate sterile technique into practice according to
agency policy
IB 4
IB 5
IC 1
Perform point of care testing per lab and unit protocols
by completing all required competencies
IC 2
Utilize protocols and other references for unfamiliar or
infrequently used procedures and equipment
IC 3
Administer oxygen safely as ordered
IC 4
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 2
References
Learning Guide #
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Preceptor initials
Verification method
& facility specific requirements
Learner initials
Required Competencies
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Date all met
Self-assessment
RN Competency Form: Generalist
Perform the following types of suctioning as apply:
trach suctioning
naso or oropharyngeal
bulb, yankaur, olive tip
Manage a nasogastric tube per protocol
IC 5
Implement pain management protocol
initiate pain pump(s) used in unit (RN only)
IC 7
Manage patient pre-, during, and post-procedure per
protocol
IC 6
IC 8
Also see separate comp for
procedural sedation if applies
Perform wound care consistent with protocols
IC 9
Incorporate regulatory requirements into practice
IC 10
Section II. The learner will incorporate relevant communication skills in all interactions to include the following:
Document care given and patient response accurately in
health care record.
II 1
Interact in a respectful and collaborative manner with
the healthcare team.
II 2
Report pertinent, concise information to team members
per policy
II 3
Demonstrate verbal and nonverbal therapeutic
communication with patients and staff
II 4
Section III. The learner will incorporate critical thinking skills in delivery of all nursing care to include the following:
Analyze patient laboratory data to use it in clinical
decision making
III 1
Manage unit phone calls per policy
III 2
Prepare for moving a patient between levels of care
within the facility or to/from another facility
III 3
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 3
References
Learning Guide #
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Preceptor initials
Verification method
& facility specific requirements
Learner initials
Required Competencies
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Date all met
Self-assessment
RN Competency Form: Generalist
Use resources effectively
respond to significant changes in patient status per
protocols and orders
notify charge nurse or manager of significant
changes or needs on unit
Anticipate potential unit / patient crises and act to
prevent them or minimize their impact
III 4
Perform nursing role within scope of practice, unit
limitations and individual competency
use reflective judgment in self-assessment &planning
recognizes own limitations
create a plan for ongoing development of decision
making ability
III 6
Section IV. The learner will incorporate human caring & relationship skills in all interactions to include the following:
Advocate for patient and family needs
III 5
IV 1
Assist patient/family with ethical and/or legal issues with
sensitivity
IV 2
Display empathy, compassion and respect to patients
and families
IV 3
Maintain patient privacy and confidentiality at all times
IV 4
Assist colleagues with care delivery
IV 5
Incorporate cultural competence and respect for
diversity into practice
IV 6
Provide palliative care as part of the continuum of care.
IV 7
Section V. The learner will incorporate management skills in all interactions to include the following:
Plan shift to accomplish tasks and goals
organize workload effectively
prioritize and reprioritize work as needs change
complete tasks or seek help
Manage assignment
complete full patient assignment
ask for advice and delegate as needed
V1
V2
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 4
Manage self
manage personal professional development
keep certifications, license & employee health
records current, wear appropriate attire and ID
maintain calm, professional behavior during stressful
situations
use correct body mechanics and resources to
prevent injury
Identify area of interest in quality improvement
(committees, projects, workgroups, etc.)
Section VI. The learner will incorporate leadership skills in all interactions to include the following:
Complete Clinical Nursing Leadership Competence
Complete leadership competency
form if required (charge nurse,
manager, house supervisor,
preceptor, etc.)
References
Learning Guide #
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Preceptor initials
Verification method
& facility specific requirements
Learner initials
Required Competencies
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Date all met
Self-assessment
RN Competency Form: Generalist
V3
VI 1
Supervise staff
monitor performance of supervised staff
assist staff as needed
provide feedback to staff & management as needed
VI 2
Delegate work fairly and according to skill level and
scope of practice
VI 3
Coordinate care with healthcare team
VI 4
Initiate chain of command
VI 5
Section VII. The learner will incorporate teaching skills in delivery of all nursing care to include the following:
Educate patients and families with consideration for age,
culture, educational background and home environment
or setting
VII 1
Provide education to complete a successful patient
discharge per policy
VII 2
Coordinate education to ensure the patient gets a
consistent message
VII 3
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 5
References
Section VIII. The learner will incorporate knowledge integration skills to include the following:
Identify care issues within the rural environment
Learning Guide #
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Preceptor initials
Verification method
& facility specific requirements
Learner initials
Required Competencies
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Date all met
Self-assessment
RN Competency Form: Generalist
VIII 1
Provide nursing care that is evidence based
VIII 2
Use all computer systems successfully
VIII 3
Accept teaching, coaching and mentoring to improve
competence
VIII 4
Seek continued learning opportunities to improve
practice
VIII 5
Comments/alternative learning plans:
All preceptors are to sign & initial below. Ideally new graduates should have only one to two preceptors for the entire orientation.
Preceptor Signature
Initials
Preceptor Signature
Initials
Signatures at completion of preceptorship/orientation:
Preceptee/orientee
Date
Primary Preceptor
Date
Manager
Date
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 6
RN Competency Form: Generalist
LEARNER GUIDE: Reference content in the right-hand column that needs review.
IA. The learner will incorporate relevant assessment & intervention (A&I) skills in delivery of care to include the following:
IA 1
Initiate life-saving/emergency measures consistent with
Review procedures for:
patient needs and protocols
-Correct response for all codes
-Obtaining/interpreting an ECG
-Emergency intubation
-Allergic reaction (also latex allergy)
-Seizure precautions including patient positioning/padding
-Hyper and hypoglycemic episodes
-Hyper and hypothermic episodes
-Suicide prevention precautions
-Nonviolent crisis intervention
-Pediatric emergencies (including medication dosing and crash cart supplies
-GI, post partum, other significant bleeds
-Reporting abuse/neglect
-Use of emergency equipment
-Cardiac emergencies
-Poison/overdose management
IA 2
Conduct initial assessment to identify patient’s needs and
priorities of care (full physical assessment--RN only,
LPN’s may perform limited, targeted assessments)
Review the following:
-How to complete all intake forms & processes
-How to complete assessment to identify primary needs of patient
-How to distinguish abnormal from normal signs and symptoms
-How to address age specific needs
-Immunization policies (Review vaccination database--VAK TRAK or other)
-Policy for treatment of minors and at risk adults
-Skin integrity assessment and protocols
-Physical, psychological, social and spiritual aspects of assessment
IA 3
Develop individualized plan of care that reflects current
practice standards (RN only)
Implement plan of care based on patient-related data and
best practices
Integrate developmental and age specific needs in
approach to and delivery of care
Review care plan process and documentation requirements
IA 6
Use equipment based on age, weight and need
Review the use of equipment (scales, pumps, restraints, lifts, etc.) in regards to
age and weight.
IA 7
Implement measures and precautions to insure patient
safety and well-being
Review the following:
-Wandering & fall prevention protocols
-Patient identification measures
-Restraint and seclusion policy including: assessing need for continued
restraint, using least restraint necessary, and monitoring for
complications/patient needs
-Infection control policy including hand hygiene, personal protective equipment,
patient isolation (respiratory, wound, neutropenic, etc.) and contaminated
waste policies
-Nosocomial risks: delirium, UTI’s, central line infections, pressure ulcers, etc.
-Unusual occurrence reports
IA 4
IA 5
Review priority setting practices and discharge criteria
Review the following:
-VS parameters
-Communication techniques
-Physical, developmental, spiritual & emotional needs
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 7
RN Competency Form: Generalist
LEARNER GUIDE: Reference content in the right-hand column that needs review.
IA 8
Promote increase in client independence
Review physical, occupational and speech therapy procedures, introduce to
PT/OT/ST team, review resources & equipment available and methods to
support family involvement
IA 9
Implement mental health & alcohol/substance abuse
behavior protocols
Review mental health policies re: suicide watch, behavioral management,
consultations
Review alcohol/substance abuse protocols and pathophysiology
Review process for transferring to other facilities
IA 10
Manage patient on cardiac monitor
Review procedures and monitoring equipment and policies for handling
abnormal rhythms
Review rhythm interpretation
IA 11
Manage nutritional support - recognize need
Review protocols, available types of tube feeding, nutritional supplements and
diets.
Introduce to dietary personnel
IB. The learner will incorporate relevant A & I skills in delivery of medications, IV’s & blood to include the following:
IB 1
Administer medication to assigned patients
Review medication administration policies and reference materials including
med reconciliation and narcotic accounting
Introduce to pharmacist and review pharmacy role and availability
Must pass unit/hospital medication test if required before allowed to administer
meds
Review limits to medication administration (formulary, restricted meds, high
alert meds)
IB 2
Manage peripheral IV care consistent with protocols
Practice with related equipment (syringe pump, IV pump and corresponding
supplies)
Review policies re: preparing IV meds, approved IV medication list per unit
Review geriatric and pediatric considerations re: volume and dosages
IB 3
Manage central/PICC line consistent with protocols
NOTE: LPN’s limited to specific training per state statutes
Review policies on flushing, drawing blood, declotting, dressing change,
removal and general care of all central catheters used in the facility (PICC,
triple lumen, groshong, portacath, etc.)
Complete any specialty line competencies as required
IB 4
Administer blood/blood products (RN only) per protocol
Review blood bank and nursing policies and procedure for transfusion of blood
products
Review actions to take if suspected reaction occurs
Review massive transfusion, autologous transfusion and giving uncrossmatched blood policies
IB 5
Perform venipuncture on an adult &/or child or infant heel
stick as applicable
Review lab and nursing policies related to blood sampling
Review blood culture protocol
IC. The learner will incorporate relevant A & I skills in performing procedures & utilizing equipment to include the following:
IC 1
Integrate sterile technique into practice according to
If not demonstrated in patient care, have learner simulate a sterile dressing
agency policy
change, foley insertion or other sterile procedure.
IC 2
Perform point of care testing per lab and unit protocols by
completing all required competencies
Review testing and quality control for the following as apply: rapid strep,
glucometer, urine chemistry strip, occult blood, urine pregnancy tests, iStat,
Ferning test
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 8
RN Competency Form: Generalist
LEARNER GUIDE: Reference content in the right-hand column that needs review.
IC 3
Utilize protocols and other references for unfamiliar or
Review how and where to access all procedures, manuals and instructions.
infrequently used procedures and equipment
Infrequent procedures may include post-mortem care, organ donation, and
many others
Equipment may include heating or cooling devices, fluid warmers, and many
others
IC 4
Administer oxygen safely as ordered
Review types of O2 equipment (cannula, NRB, BVM, ventimask and aerosol
mask, tanks, etc.)
Review O2 monitoring and signs of toxicity
Set up and use pulse oximetry
Review peak flow measurement
IC 5
Perform the following types of patient suctioning as apply
Review procedures for suctioning including safety considerations
IC 6
Manage a nasogastric tube per protocol
Review protocols including how to assess placement/proper function
Practice insertion as needed
IC 7
Implement pain management protocol
Review policies
Assess and reassess every patient for pain
For epidural, and PCA: specifically review equipment manual, pain
management techniques, teaching, troubleshooting and documentation
Review role of anesthesiology dept for epidurals
IC 8
Manage patient pre-, during, and post-procedure per
protocol
Review pre-op preparation and paperwork including site check
Review protocols (including time out) for procedures performed in the unit
(thoracentesis, paracentesis, spinal tap, etc.)
Review protocols for post-op/unit procedure recovery & potential complications
IC 9
Perform wound care consistent with protocols
Review procedures and equipment (wound vacc, drains, etc.)
Introduce to any resource personnel (ostomy/wound care nurse)
IC 10
Implement regulatory requirements into practice
National patient safety goals, CMS guidelines, Joint Commission, core
measures, etc.
Section II. The learner will incorporate relevant communication skills in all interactions to include the following:
II 1
Document care given and patient response accurately in Review charting policy, forms, and computer programs.
health care record.
II 2
Interact in a respectful and collaborative manner with the Meet team members and review roles and responsibilities of each
healthcare team.
II 3
Report pertinent, concise information to team members
Review hand-off report, info to share with charge nurse, manager, MD’s, etc.
per policy
Review how to reach team members (pager, phone, etc.)
II 4
Demonstrate verbal and noverbal therapeutic
communication with patients and staff
Review care models for the organization (rounding, family driven care, etc.)
Review organizational behavior standards
Section III. The learner will incorporate critical thinking skills in delivery of all nursing care to include the following:
III 1
Analyze patient laboratory data to use it in clinical
Review lab norms and reports including fluid and electrolyte management and
decision making
critical values
III 2
Manage unit phone calls per policy
Review telephone triage policy (RN only)
Review Health Aide roles and capabilities
Review types of calls, scope of practice and information sharing limitations
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 9
RN Competency Form: Generalist
LEARNER GUIDE: Reference content in the right-hand column that needs review.
III 3
Prepare for moving a patient between levels of care
Review ground and air transfer policies and logistics
within the facility or to/from another facility
Review EMTALA and medivac protocols
III 4
Use resources effectively
Review order sets and protocols and notification process
Review after hour protocols, acuity process, supplies, etc.
III 5
Anticipate potential unit / patient crises and act to prevent
them or minimize their impact
Review frequently occurring unit patient intervention needs
Review unusual occurrence reporting system
Discuss failure to rescue
Review rapid response team role if available
III 6
Perform nursing role within scope of practice, unit
limitations and individual competency
Review ANA and specialty standards, nurse practice act
Review limitations of unit and competency process
Section IV. The learner will incorporate human caring & relationship skills in all interactions to include the following:
IV 1
Advocate for patient and family needs
Review policy for patient complaints, advocacy and ethics
IV 2
Assist patient/family with ethical and/or legal issues with
sensitivity
Review policy and resources for patient rights, advocacy, code status, living
wills, POAs, etc.
IV 3
Review customer service guidelines and mission statements
IV 4
Display empathy, compassion and respect to patients
and families
Maintain patient privacy and confidentiality at all times
IV 5
Assist colleagues with care delivery
Review teamwork behaviors
IV 6
Incorporate cultural competence and respect for diversity
into practice
Discuss local cultural beliefs and practices that impact healthcare, interpreter
procedures, pastoral care, social services, etc.
IV 7
Provide palliative care as part of the continuum of care.
Review guidelines on pain and other symptom management
Review education and support systems that help patients live as actively as
possible until death
Introduce to team and team approach to address needs of patients and
families, including bereavement counseling
Review confidentiality procedures for medical records, unit privacy, HIPPAA,
and private places to talk
Section V. The learner will incorporate management skills in all interactions to include the following:
V1
Plan shift to accomplish tasks and goals
Review unit shift expectations and time management techniques
V2
Manage assignment
Review position descriptions and capabilities of other staff on the unit
V3
Manage self
Review unit and hospital requirements, lift policies, employee safety process,
dress code, etc.
Review quality process used in facility
Section VI. The learner will incorporate leadership skills in all interactions to include the following:
VI 1
Complete Clinical Nursing Leadership Competence
Review policies along with the competence form including staffing, acuities,
disaster management, etc.
VI 2
Supervise staff
Review position descriptions
VI 3
Delegate work fairly and according to skill level and
scope of practice
Introduce to all unit staff and describe their job responsibilities and limitations
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 10
RN Competency Form: Generalist
LEARNER GUIDE: Reference content in the right-hand column that needs review.
VI 4
Coordinate care with healthcare team
Introduce to all professional and support team members, review their roles &
contact procedures
VI 5
Initiate chain of command
Review organizational structure and situations requiring notification
Section VII. The learner will incorporate teaching skills in delivery of all nursing care to include the following:
VII 1
Educate patients and families with consideration for age, Review teaching principles and local culture and resources
culture, educational background and home environment
or setting
VII 2
Provide education to complete a successful patient
Identify community resources for the patient
discharge per policy
Review discharge policy and procedures (pharmacy, standardized teaching
materials, etc.)
VII 3
Coordinate education to ensure the patient gets a
Review standards for patient education
consistent message
Section VIII. The learner will incorporate knowledge integration skills to include the following:
VIII 1 Identify care issues within the rural environment
Discuss general rural care issues & those specific to each rural site
Problems common in frontier areas: older population, socioeconomic status,
access, transportation and financial issues, employee benefits, fewer
practitioners
Rural nurse generalist concepts: isolation and distance, lack of anonymity, old
timer/newcomer and insider/outsider, informal networks, rural concepts of
health, definition of health, possibly delayed treatment seeking, self reliance,
cultural issues, boundary expansion and pinch hitting, “practicing medicine”
without a license, family centered care, career development and education,
accessing patient care information on the fly
VIII 2
Provide nursing care that is evidence based
Review computer/library resources, local experts and classes
VIII 3
Use all computer systems successfully
Obtain computer systems training
VIII 4
Accept teaching, coaching and mentoring to improve
competence
VIII 5 Seek continued learning opportunities to improve
practice
Other facility specific items to cover:
Review resources available for learning
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 11
RN Competency Form: Generalist
REQUIREMENTS: All nurses will complete these competencies upon hire. Some competencies may be reviewed annually. This form
follows the Competency Outcomes and Performance Assessment (COPA) model.
PRECEPTEE/LEARNER INSTRUCTIONS:
Complete self-assessment: Rate your skill in each area to identify the areas where you need additional experience, access to teaching
resources, and/or lab practice. Discuss your results with your preceptor to help establish a plan and goals for your learning experience
and to aid in choosing patient assignments. Scoring per instructions at the top of page 1.
PRECEPTOR INSTRUCTIONS:
A. Review self-assessment with preceptee/learner to establish plan.
B. Required Competencies: The specialty area competency forms are required for independent practice on this unit. This column
represents the Alaska Statewide required competencies per ACE-HC and should not be altered. The preceptor will sign each one off
when he/she, as preceptor and colleague, feels safe in allowing the preceptee/learner to deliver this aspect of care without
direct supervision.
C. Verification Method & Agency Specific. Document comments/check marks for the competency and any agency specific
requirements. Verification methods include:
1. Demonstration – Preceptor watches learner perform task/procedure in safe, capable manner in a simulated lab or computer
setting or as part of direct care performance. The expectation for new graduates is that they demonstrate as many of the
competencies as possible.
2. Test – Learner passes a test provided by the facility to measure competence for this skill. (Minimum passing grade indicated.
Initial only after test passed.)
3. Module –Learner has completed a training tool (computerized or written module, class, video, etc.) provided by the facility to
measure competence for this skill.
4. Verbalization - Learner explains to the preceptor the process and/or planning that evidences safe, reliable knowledge base. This
may include case scenarios, discussion, and/or description of plan.
NOTE: some competencies may have the verification method specified per facility guidelines (e.g. “test only”)
Record N/A and initials only for items that never apply to this learner’s role or performance.
D. Sign-off: Sign and date when all elements of the competency are met. If unable to sign off an area due to patient population issues
or learner needs more time, document a plan in the comments section at the end of the form. Discuss alternative ways of meeting the
requirement(s) as well as any additional time needed with the nurse manager and/or nurse educator. All preceptors assisting in
orientation of a new staff member/intern must sign and initial in the signature chart at the end of this document.
E. References: Competencies should be met in accordance with these. Add your facility approved references here.
F. Learning Guide: These are memory ticklers. The amount of time spent on each of them depends on the learner’s experience. New
graduates will likely need time on almost all of the areas listed.
REFERENCES COLUMN: List foundational documents to support the learning experience and to use as the official measure by which
the competencies are assessed. The ACE-HC group recognizes the following as sources for evidence based practice that can be
included in the reference list along with local policies, procedures and forms: Perry & Potter, Elsevier/Mosby, Lippincott, Kozier & Erb,
ANA, nationally recognized hospital related regulatory organizations (CLIA, CDC, CMS, JC, etc.), and specialty nursing organizations’
scope, standards and core curricula. This column’s content may be changed to be facility specific.
NOTE: ACE-HC competency forms are intended to be used between facilities within Alaska.
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 12