COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia

Ministry of health
General Nursing Directorate

Competency Check List:PATIENT AND FAMILY RIGHTS AND RESPONSIBILITIES

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment
VA = Verbal Assessment Method

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Differentiate between patient right's
and patient's responsibly.
B.SKILLS:
MAINTAIN PATIENT'S PRIVACY
Do not raise the voice when
1.1
addressing patient.
Do not open the lights of patients
1.2
room without permission.
Patients should be examined by the
1 1.3
internist in the internist room only.
The nurse must keep the patient
1.4 covered during examination and
nursing care.
The door of internist room must be
1.5 closed before starting any
procedure
PATIENT CONFIDENTIALITY
Nursing staff must be aware of
the confidential nature of
2 information obtained in daily
2.1 practice. If information is not
pertinent to a case, the nurse should
question whether it is prudent to
record it in patient chart.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
Discussions regarding patient case
should never occur in a public area
2.2
where it is not unlikely that the
conversation will be overheard.

The nurse must not allow any

person not responsible for a patient
2.3
to access to medical record or check
any results of investigation
PATIENT SAFETY AND SECURITY
Patient has to be treated in good and
3.1
healthy environment.
Treatment area has to be safe and
3.2 secure and protected from possible
harm.
Separate the adolescent patients
3.3 from the adult ones (adolescent
unit).
Separate patients with special
3.4 observations (special care unit)
from the general population.
Patients with special observations,
i.e. 1:1 observations, should be
3.5 monitored closely and
documentation maintained at
regular times.
INFORMATION
Give full information to patients
4.
regarding rights and responsibilities
1
in either verbal or written form.
4. Orient patient about treatment and
2 stay
Introduce all members of the
4.
medical team and the specialty of
3
each.
4. If available, provide translator for
4 non-Arabic speaking staff.
MEDICAL REPORT
Patient has right to get medical
5.1
report after treatment.
Notify social worker that a certain
5.2 patient is to be discharged and
needs Medical Report.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
It is the responsibility of the Social
Worker Department to
5.3 communicate with the Medical
Record regarding the issuance of
the medical report.
Advise patient to report to Patient
5.4 Services department in OPD to
secure the report upon discharge.
C.ATTITUDE:
Respects for patient's life, dignity,
1
privacy rights and safety.
Treats patient information with integrity
2
and confidentiality.
D.STAFF COMMENTS:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

E.VALIDATORS COMMENTS:
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________
F.PLAN:
_______________________________________________________________________________________
______________________________________________________________________________________
G.REFERENCES:
1. Fundamentals of Nursing, 4th Edition by Taylor
2. Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
3. Lippincott Nursing Procedures, 5th edition, 2009 by Williams & Wilkins

NAME POSITION SIGNATURE DATE

ASSESSOR:
CANDIDATE
NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:PATIENT EDUCATION

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Method
Comment
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
To give the patient appropriate information
1
about their illness and required nursing care.
B.SKILLS:
The nurse must coordinate with the physician
1 and other health care providers to plan the
education.
Assessing the patient's capability and
2
motivation to provide self-care
Providing the appropriate/accurate
3 information about the illness to the patient
and family members
Give the patient answers about;
4.1 Treating as in-patient or out-patient
4.2 How many days he will stay in the
4 hospital if the patient asks.
4.3 What procedures are required to
laboratory test, X-ray, surgical
procedures and others?
Provide the patient with the required
5 nursing care and explain the importance of
nursing care to the patient's condition.
Provide information about diet of the
6 patient, any restrictions of diet and reasons
why restrictions are necessary.
Explain about the proper use of
medications, e.g. insulin and hypertensive
7
drugs, proper use of medical equipment at
hand.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
Patient must be educated regarding use of
8 medical equipment's i.e. nebulizer, for
safety.

The medications used for treatment and

9 the frequency of taking the medicines and
their side effects.
Teaching and providing information to the
10 patient about infection control guidelines and
personal hygiene.
Explains and teaching the appropriate use of
11
medical equipment's or appliances
Provide the guidelines and information about
12
how to use equipment's (Glucometer).
Demonstrate how to use medical equipment's
13 or appliances like inhalers for asthmatic, use
of pamphlets, diagrams and charts.
Patient education materials as: pamphlets,
14
video tapes, and audio tapes.
Patient follow up to clinic when, what time
15
with various report and medication, etc.
Explaining when the patient should seek
16 medical assistance by telephone in what
conditions.
Explaining in what condition it is necessary
17 that the patient reporting to Emergency
Room.
Every time education given the patient must
be asses for understanding of education and
18 how much he learned or grasped. By
verbalized education given and/or return
demonstration.
All education given to the patient and family
19
must be documented in the patients file.
Patients response, feedback to learn must be
20
documented in the patient education form.
C.ATTITUDE:
Recognizes patient's value and
1
psychological needs.
Acknowledges patients cultural
2
background in patient teaching.

D.STAFF COMMENTS:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
_______________________________________________________________________________________________
__________________________________________________________________________________________

E.VALIDATORS COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
F.PLAN:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
G.REFERENCES:

1. Fundamentals of Nursing, 4th Edition by Taylor

2. Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
3. Lippincott Nursing Procedures, 5th edition, 2009 by Williams & Wilkins

NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
Competency Check List:TRANSCRIPTION OF PHYSICIAN'S ORDER

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment
Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
Definition of transcription of physician's
1
order
B.SKILLS:
The following identification details will be
written in all transcription sheets:
1.1 Name.
1.2 Medical Record Number
1
1.3 ID Number
1.4 Age
1.5 Unit
1.6 Date of Admission
A recent photograph of the patient should be
2 attached to the left top corner of the
transcription sheet (if it is available).
Any known drug allergies should be written
3
in the appropriate box.
If there are no known drug allergy, the words
4
NIL, KNOWN or N/K should be written.
The prescribing doctor's name must be
5
written.
The name of medication transcribe will
correspond exactly to that written in the
6 medication order, regardless of whether this
is the trade or generic name of the
medication.
The dose of the medication transcribed
7 should correspond to the available stock that
is dispensing by the hospital pharmacy.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
The number of tablets / drops / misc. to be
dispensed at each prescribed medication time
8
will be written beside the time for
administration.
The route of administration will also be
9
written.
The date that the medication is to commence
10
will also be written.
The nurse who transcribed the medication
11 order will identify himself by signing and
printing clearly his name.
The nurse who receives the physician's order
should affix his signature in the physician's
12
order, with name clearly written, with date
and time before removing the order.
A recent photograph of the patient should be
13 attached to the left top corner of the
transcription sheet (if it is available).
C.ATTITUDE:

1 Respect for patient's rights & safety.

D.STAFF COMMENTS:
_______________________________________________________________________________________________
______________________________________________________________________________________________

E.VALIDATORS COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________

F.PLAN:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
G.REFERENCES:

a. Fundamentals of Nursing, 4th Edition by Taylor

b. Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
c. Lippincott Nursing Procedures, 5th edition, 2009 by Williams & Wilkins

NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:Nursing Documentation

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment Validation
Comment
VA = Verbal Assessment Method

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 State purpose of nursing documentation.

2 Awareness of general principles or policy of

documentation.
B.SKILLS:
1 Writes neatly and legibly

2 Use correct spelling and grammar

Write clear and concise sentences.
Avoid useless and unnecessary
words.
Clearly identify the subject of the
sentence.
Consult the dictionary if in doubt.
3 Documentation should be organized.
Use blue or black pen only
Write the date and use military time
during each entry with the nurse
signature (complete name, or first
initial followed with the family
name).
4 Use authorized / standard abbreviations
only.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

5 Document complete information about

medication, patients response to any
treatment and patients condition.
Write the date, time and initials
Document sites of all parenteral
injections including date and time
of insertion.
When you omit a medication,
document why, and refer to
physician.
6 Chart Promptly
Chart as soon as an observation,
nursing care, treatment or
procedure is done.
Never chart nursing care or
observations ahead of time.
7 Clearly identify care given by another
member of the health care team.
8
Dont leave any blank spaces on chart
forms.
In case a space is left out, draw a
line across the space and write the
word SPACE.
9 Correctly identify late entries
Add the entry to the first available
space
Record the date & time and write
Late Entry.
Document the entry, record the
date and time it should have been
made.
Dont squeeze a late entry into an
existing note or write it in the
margins
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
10 Correct mistaken entries properly. Never
use white out or liquid eraser.
Draw a single line across the
mistaken entry. Write Mistaken
Entry or ME, on top of the
error and sign at the end of the
entry.
11 Dont sound tentative.
Be exact and specific. Avoid
words such as appears, apparent,
these words conclude that you
did not know what you were
doing.
12 Write your full name legibly.
When writing your notes on the
last line of the page.
When closing your notes at the
end of your shift.
C.ATTITUDE:
1 Writes in appropriate spaces, date and time
of each entry and legible signature of the
nurse.
2 Document patients response to any
treatment and patients general condition.
3 Treat patient information with integrity and
confidentiality.
4 Accepts correction on documentation with
open mind.
D.STAFF COMMENTS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____
E.VALIDATORS COMMENTS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____
F.PLAN:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
______
G.REFERENCES:
1. Fundamentals of Nursing, 7th Edition by Kozier, Erb, Berman, Snyder
2. Ministry of Health Policy and Procedure CD 1425

NAME POSITION SIGNATURE DATE

ASSESSOR:
CANDIDATE
NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: SAFETY ISSUES INCLUDING ELECTRICAL

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment
Validation
Method Comment
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Awareness of the nurses responsibility
regarding safety issues.
2 Awareness of the proper handling and
disposal of wastes.
3 Verbalizes understanding on the
implementation of safety practice in case
of accidents in the hospital.
4 Demonstrate proper handling and
maintenance of equipments.
B.SKILLS:
1 Awareness of the nurses responsibility
regarding safety issues.
2 Awareness of the proper handling and
disposal of wastes.
3 Verbalizes understanding on the
implementation of safety practice in case
of accidents in the hospital.
4 Demonstrate proper handling and
maintenance of equipments.
C.ATTITUDE:
Maintains clean and safe environment
1 for patient.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
Document any incident / accident and
2 the action taken.

D.STAFF COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

E.VALIDATORS COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

F.PLAN:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

G.REFERENCES:
1. Fundamentals of Nursing, 4th Edition by Taylor
2. Medical Consultant Network Incorporated ( CD )

NAME POSITION SIGNATURE DATE

ASSESSOR:
CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:PATIENT FALLS

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Method Comment
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:

1 Definition of patient fall.

2 Reasons of patient fall.

B.SKILLS:
Upon admission, orient the patient with the
1 environment room, bed, toilet, doctor's
room, meeting room, etc
Demonstrate to patient ways to obtain help
2
when needed.
Placed bed in low position with brakes
locked if possible, or placed the mattress on
3 the floor (particularly for patients who are
prone to falls, history of frequent fall, or
patient at high risks of falling.
If patient is alone, instruct the patient to
4
utilize the help of the nearest person around.
Make sure that footwear is fitted and not
5
slippery and is used properly.
6 Utilized night light.
7 Keep floor surface clean and dry.
Make sure that patient knows where personal
8 belongings are, and that he can safely and
easily access them.
9 Ensure adequate hand rails in the bathroom.
Evaluate effects of medication that
10
increases the risk of patient fall.
In case of occurrence of patient falling down
Call for assistance and inform the charge or
11
the head nurse.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
At least two members of the nursing staff in
12
the unit must care for the patient.

Assess patient for any injuries, especially

13 cervical and spinal injury, and patients level
of consciousness (LOC).
Move patient as a whole (log roll),
14
supporting the neck and spine.
15 Place wooden board under the patient.
Turn patient back over the wooden board in
16
supine position.
Carry patient to treatment room using the
17 wooden board moving in synchronized
manner.
Transfer the patient to the treatment room
18 bed lifting the patient from the wooden board
to the bed (moving as one).
19 Check for vital signs
Carry out Doctors order&Document in the
20
file
C.ATTITUDE:

1 Respect for patient's life & safety.

Exhibits appropriate level of concern for falls
2 prevention.

D.STAFF COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
E.VALIDATORS COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
F.PLAN:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
G.REFERENCES:
Fundamentals of Nursing, 4th Edition by Taylor
Medical Consultant Network Incorporated ( CD )
NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: Nursing Care Of Patient At End OF Life

Position Title: Staff Name: Unit: ID
No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment Validation Comment
VA = Verbal Assessment Method

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Able to demonstrate communication skill,

2 Able to provide physical comfort, social

spiritual needs
B.SKILLS:
1 Communicate effectively and
compassionately with the patient family and
health care team about the end of life care.

2 Facilitate participation in religious or

spiritual activities
3 Assess patient daily and provide care
needed
4 Providing Physical and environments
Comfort
5 Provide emotional support not only to the
patient but also to family and friends.

6 Administer medication as needed

C.ATTITUDE:
1 Respects patient's rights & accepts behavior
in response to the procedure
2 Recognizes patient's value and psychological
needs.
3 Treats patient information with integrity and
confidentiality
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

E.VALIDATORS COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

F.PLAN:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

G.REFERENCES:

.1Fundamentals of Nursing, 4th Edition by Taylor

.2Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
3.Lippincott Nursing Procedures, 5th edition, 2009 by Williams & Wilkins

NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:PULSE OXIMETRY

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment
Validation
Method Comment
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 State the purpose of monitoring oxygen
saturation.
2 Verbalizes understanding of pulse
oximetry (IPP)
3 Recognize signs of recovery and
deterioration.
B.SKILLS:
1 Identifies correct patient by using 2
patient identifiers.
2 Use proper equipment. Probe should be
appropriate to patients size and age.
3 Select appropriate site of saturation
probe, sensor is properly positioned
4 Clean selected area and allow drying.
5 Apply the saturation probe properly and
securely to the patients skin.
6 Connect sensor probe to pulse oximeter.
7 Oxygen saturation default alarm limits
are set according to patients condition.
8 Assess patients oxygenation including
heart rate, respiratory rate and blood
pressure.
9 Maintains skin integrity on the sensor
site.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
10 Changing the location of the saturation
probe every 4-6 hours.

C.ATTITUDE:
1 Wash hands before commencing the
procedure. Explains rationale for using
standard precaution.
2 Document all relevant information in
appropriate manner.
D.STAFF COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

E.VALIDATORS COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

F.PLAN:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

G.REFERENCES:
1. Taylors Clinical Nursing Skills A Nursing Process Approach, by Pamela Evans-Smith
2. Perfecting Clinical Procedures, 2008 by Lippincott Williams & Wilkins
3. Nursing Procedures, 5th edition by Lippincott Williams & Wilkins
NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:PAIN MANAGEMENT

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment
Validation
Method Comment
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Define Pain?

2 State the purpose of pain assessment

and pain management.
3 Identifies the tools/scale used in
assessing pain.
4 Enumerates the non pharmacology&
pharmacological management for pain.
5 Knows how to use the pain assessment
flow sheet.
B.SKILLS:
1 Includes assessment of pain upon
patients admission.
2 Responds immediately to patient
complaining of pain.
3 Assess the patient and identifies the
following:
4 3.1 Intensity of pain & what
aggravates it
5 3.2 Quality of pain
6 3.3 Frequency of pain.
7 3.4 Location of pain
8 Identifies the intensity of pain
according to the scale ( 0 - 10 ).
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
9 Knows and applies non
pharmacological interventions for mild
pain.
10 Assess patients vital signs prior to
administration of ordered narcotic or
any potent analgesic.
11 Reassess patient after nursing
intervention and administration of
analgesic.
C.ATTITUDE:
1 Respect patient life, dignity, privacy right
and safety.
2 Explain the patient's and family's role in
the management of pain.
3 Educate patient and relatives regarding
pain management.
4 Provide emotional support.

5 Keep patients free from pain and

functional.
D.STAFF COMMENTS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
E.VALIDATORS COMMENTS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
F.PLAN:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
G.REFERENCES:
1. Fundamentals of Nursing, 4th Edition by Taylor
2. Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
3. Lippincott Nursing Procedures, 5th edition, 2009 by Williams & Wilkins
NAME POSITION SIGNATURE DATE

ASSESSOR:
CANDIDATE
NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: TRACHEOSTOMY CARE

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment
Validation

Comment
Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Define Tracheostomy.

2 What are the standard concerns of a

nurse taking care of a patient with
artificial airway?
3 Able to suction the trachea and pharynx
thoroughly before Tracheostomy Care.
B.SKILLS:
1 Enumerate the equipments needed for
Tracheostomy Care.
2 Identifies correct patient by using 2
patient identifiers
3 Able to assess condition of stoma before
Tracheostomy Care.
4 State the purpose of Tracheostomy Care

5 Demonstrate the correct procedure of

Tracheostomy Care observing sterile
aseptic technique.
C.ATTITUDE:
1 Explain procedure to patient/parents

2 Report any abnormal changes on the

tracheostomy site.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
3 Document response to procedure.

D.STAFF COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
E.VALIDATORS COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
F.PLAN:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________
G.REFERENCES:
1. Taylors Clinical Nursing Skills A Nursing Process Approach, by Pamela Evans-Smith
2. Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
3. Nursing Procedures, 5th edition by Lippincott Williams & Wilkins
NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: SUCTIONING

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment
Validation

Comment
Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 States purpose of suctioning

2 Awareness of complication resulting from

improper suctioning.
3 Demonstrates standard precaution and
proper waste disposal.
B.SKILLS:
1 Identifies correct patient by using 2
patient identifiers
2 Monitor heart rate and auscultate breath
sounds prior to suctioning.
3 Identifies physiological needs for
suctioning.
4 Ensures correct patient positioning prior
to procedure.
5 Demonstrates correct hand washing
technique and principles of asepsis
6 Collects necessary equipments:
Checks function of suction
and oxygen source.
Selects suction catheter
appropriate to size of patient.
Selects suction pressure
range appropriate to patient.
7 Understands the purpose of
hyperventilating patient prior to
suctioning.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
8 Demonstrates awareness of the
clinical factors which influence the use
of saline lavage during suctioning
procedure.
9 Performs chest physiotheraphy prior
to procedure

10 Demonstrates correct suctioning

technique.
11 Demonstrates awareness of the
potential complications which may
occur during suctioning and how to
prevent / manage them.
12 Rinse catheter with normal saline
between suctioning.
C.ATTITUDE:
1 Explains procedure to patient or
relatives.
2 Assess patients physiological
condition during and following
completion of procedure.
3 Evaluate and document patients
response to suctioning.
D.STAFF COMMENTS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
E.VALIDATORS COMMENTS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
F.PLAN:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
G.REFERENCES:
1. Taylors Clinical Nursing Skills A Nursing Process Approach, by Pamela Evans-Smith
2. Perfecting Clinical Procedures, 2008 by Lippincott Williams & Wilkins
3. Nursing Procedures, 5th edition by Lippincott Williams & Wilkins
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
NAME POSITION SIGNATURE DATE

ASSESSOR:
CANDIDATE
NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: URINARY CATHETERIZATION FOR FEMALE PATIENT

Position Title: Staff Name: Unit: ID
No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment Validation
Method Comment
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Demonstrate understanding to policy
and procedure related to urinary
catheterization.
2 Verbalizes understanding of infection
prevention measures related to
urinary catheterization.
3 Verbalizes understanding of correct
catheter care procedure.
4 Awareness of the correct procedure
for obtaining urine specimen.
B.SKILLS:
1 Verifies physicians order.
2 Identifies correct patient by using 2
patient identifiers
3 Ensure proper position of patient.
4 Provide direct light for visualization of
genital area.
5 Wash hands, put on sterile gloves.
6 Use downward strokes to clean
urethral orifice with Normal Saline
Solution (NSS) or antiseptic solution.
7 Separates labia minora to expose the
urethral meatus, and maintain this
separation with the same hand until
procedure is completed.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
8 Lubricates the catheter before
insertion.
9 Inserts catheter into the urethral
orifice and advance catheter.
10 Allow some urine to flow through
catheter before collecting specimen.
11 Connect to drainage bag and tape
catheter to the thigh.
12 Place patient in comfortable position.
13 Wash hands after completion of
procedure.
C.ATTITUDE:
1 Explain the procedure to patient.
2 Provide comfort and privacy of the
patient.
3 Notify physician for any abnormalities
noted.
4 Document patients response to
procedure.
D.STAFF COMMENTS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________________________________________________
E.VALIDATORS COMMENTS:
_____________________________________________________________________________________________
____________________________________________________________________________________________
F.PLAN:
_____________________________________________________________________________________________
_________________________________________________________________________________________
G.REFERENCES:
1. Lippincott's Nursing Procedures 2009, 5th edition by Lippincott Williams & Wilkins
2. Lippincott's Manual of Nursing Practice 2010, 9th edition by Sandra M. Nettina
3. Nurses Guide to Clinical Procedures, 5th edition by Temple & Johnson
NAME POSITION SIGNATURE DATE

ASSESSOR:
CANDIDATE
NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:NGT INSERTION

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment
Validation

Comment
Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Identifies purpose for insertion of
nasogastric tube.
2 Comply with policy and procedure of
nasogastric tube insertion.
3 Awareness of the nurses
responsibility during insertion of
nasogastric tube.
4 Awareness of complication and
implementation of immediate
action.
B.SKILLS:
1 Verifies doctors order
2 Correct identification of patient
3 Ensure proper positioning of patient.
4 Assembles equipment at bedside.
5 Determine length of tube to be inserted.
6 Wash hands, put on gloves.
7 Lubricate NG tube with water-soluble
lubricant.
8 Carefully advances NG tube into
stomach.
9 Ensures proper tube placement.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
10 Inject 0.5 1 ml air for small infants and up
to 5 ml in larger children while listening with
stethoscope gurgling sound over
hypogastrium to verify patient.
11 Secures NG tube to the patients nose.

12 Documentation of patients tolerance to

procedure.
C.ATTITUDE:
1 Respect patient life, dignity, privacy right
and safety.
2 Introduce your-self; explain procedure and
rationale to patient or parents or relatives of
infants and small children.
3 Provide health teaching and information to
patient or parents regarding nasogastric
tube care.
4 Respect patient responses to procedure.

5 Organized and calm during performing of

procedure steps.
D.STAFF COMMENTS:
________________________________________________________________________________________________
_____________________________________________________________________________________________
E.VALIDATORS COMMENTS:
________________________________________________________________________________________________
____________________________________________________________________________________________
F.PLAN:
________________________________________________________________________________________________
______________________________________________________________________________________________
G.REFERENCES:
1. Taylors Clinical Nursing Skills A Nursing Process Approach, by Pamela Evans-Smith
2. Perfecting Clinical Procedures, 2008 by Lippincott Williams & Wilkins
3. Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:Preventing Surgical Site Infection

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment Validation Comment
VA = Verbal Assessment Method

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Identify possible causes of surgical site
infections.
2 Enumerate ways to reduce the risk of
surgical site infections.
4 State the four surgical wound
classification system.
B.SKILLS:
1 Advise patients to have a bath using
soap, either the day before, or on the
day of surgery.
2 If hair has to be removed, use electric
clippers with a single-use head on the
day of surgery. Do not use razors for
hair removal, because they increase the
risk of surgical site infection.
3 Give patients specific theatre wear that
is appropriate for the procedure and
clinical setting, and that provides easy
access to the operative site and areas
for placing devices, such as intravenous
cannulas. Consider also the patients
comfort and dignity.
4 All staff should wear specific non-sterile
theatre wear in all areas where
operations are undertaken.
5 Staff wearing non-sterile theatre wear
should keep their movements in and
out of the operating area to a
minimum.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
6 The operating team should remove
hand jewelry, artificial nails and nail
polish before operations.

VALIDATION METHOD KEY: COMPETENCY ASSESSMENT

OB = observation

(Use evaluation
RD = Return Demonstration/simulated
WA = Written Assessment

Key on Left)

Competent

Assessors
Validation
VA = Verbal Assessment Comment
Method
Other Specify: .

Initial
Date
B.SKILLS:
7 Give antibiotic prophylaxis to patients
as ordered by physician.
8 Give antibiotic treatment (in addition
to prophylaxis) to patients having
surgery on a dirty or infected wound.
9 The operating team should perform
surgical hand washing prior to
operation using an antiseptic surgical
solution.
10 The operating team should wear
sterile gowns in the operating theatre
during the operation.

11 Consider wearing two pairs of sterile

gloves when there is a high risk of
glove perforation and the
consequences of contamination may
be serious.
12 Prepare the surgical site immediately
before incision using an antiseptic
preparation: povidone-iodine or
chlorhexidine are most suitable.
13 If diathermy is to be used, ensure
that antiseptic skin preparations are
dried by evaporation and pooling of
alcohol-based preparations is
avoided.
14 Cover surgical incisions with an
appropriate dressing at the end of
the operation.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
15 Use an aseptic non-touch technique
for changing or removing surgical
wound dressings.
16 Use sterile saline for wound cleansing
up to 48 hours after surgery.

VALIDATION METHOD KEY:

OB = observation COMPETENCY ASSESSMENT
RD = Return Demonstration/simulated

Assessors
Competen
evaluation
Validation
WA = Written Assessment
Method

Key on
Comment

Initial
VA = Verbal Assessment

Date
Left)
(Use
Other Specify: .

t
B.SKILLS:
Advise patients that they may shower
17
safely 48 hours after surgery.
Provide patient and family information
and advice regarding risks of surgical site
18
infections, what is being done to reduce
them and how they are managed.
C.ATTITUDE:
1 Respects patients rights and accepts
behavior in response to the procedure.
2 Recognizes patients ability and limitation
to follow instructions.
3 Exhibit appropriate level of concern to
eliminate, prevent and control the
occurrence of infection.

D.STAFF COMMENTS:
_________________________________________________________________________________________________________
_______________________________________________________________________________________________________
E.VALIDATORS COMMENTS:
_________________________________________________________________________________________________________
_______________________________________________________________________________________________________
F.PLAN:
_________________________________________________________________________________________________________
_____________________________________________________________________________________
G.REFERENCES:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
4. Taylors Clinical Nursing Skills A Nursing Process Approach, by Pamela Evans-Smith
5. Perfecting Clinical Procedures, 2008 by Lippincott Williams & Wilkins
6. Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
NAME POSITION SIGNATURE DATE
ASSESSOR:
CANDIDATE
NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: SKIN CARE AND PREVENTION OF PRESSURE ULCERS

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
WA = Written Assessment
Validation
Method Comment
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Verbalizes understanding to skin care and
prevention of ulcers IPP.
2 Awareness of the use of Norton Scale and
Water Low Scale.
3 Awareness of the different types of skin
problem and how to care for them.
B.SKILLS:
SKIN CARE

1 Assess for development of risk factor.

a. Developing pressure sores.
b. Patient with peripheral vascular
disease with affected limbs at greater
risk.
2 Clean the skin and dry thoroughly.

3 Examine the patients skin for signs of

redness or loss of skin integrity.
4 Consult a dietician regarding patients
nutritional status.
PREVENTION OF PRESSURE ULCER

1 Wash hands.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
2 Assess patient for:
a. Risk factor that can contribute to
pressure ulcer.
b. Physical ability to help with moving
and positioning.
c. Presence of drains, incisions and
equipment.

3 Evaluate the skin for redness, rashes,

blisters, skin odor, skin peeling, skin
discoloration or pressure ulcer using the
Norton Scale.
4 Turn patient to lateral position to expose the
back. Check for any presence of pressure
ulcer.
5 Sponge the back in circular motion and dry
thoroughly paying attention to skin fold.
6 Perform dressing to pressure ulcer wound if
any.
7 Keep patient in safe and comfortable
position.
C.ATTITUDE:
1 Explain the procedure to the patient and
provide privacy.
2 Educate patient about preventive care for
pressure sore development.
3 Document the procedure and for any skin
changes identified.
D.STAFF COMMENTS:
______________________________________________________________________________________________
______________________________________________________________________________________________
__
E.VALIDATORS COMMENTS:
______________________________________________________________________________________________
______________________________________________________________________________________________
_
F.PLAN:
______________________________________________________________________________________________
______________________________________________________________________________________________
__
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
G.REFERENCES:
1. Taylors Clinical Nursing Skills A Nursing Process Approach, by Pamela Evans-Smith
2. Lippincott Manual of Nursing Practice, 9th edition by Sandra Nettina
3. Nurses Guide to Clinical Procedures, 5th edition by Temple & Johnson

NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: ASSISTING WITH INCISION AND DRAINAGE OF WOUND

Position Title: Staff Name: Unit: ID
No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Validators
Validation
WA = Written Assessment Comment

Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Define incision and drainage.
2 Identify importance of incision and drainage.
3 Identify nursing responsibilities based on
Hospitals Policy of assisting in incision and
drainage.
B.SKILLS:
1 Assess for patient's allergy to latex, any
local anesthesia or antiseptic solution.
2 Emphasize physicians explanation to
patient and family the reason and what to
expect during the procedure.
3 Ensure availability of valid consent for
procedure.
4 Prepare sterile dressing pack.
5 Put on sterile gloves.
6 Clean the site with povidone iodine and
drape the site as necessary.
7 Prepare solutions to be used for irrigation
as appropriate.
8 Administer analgesics as ordered.
9 Provide syringe for aspiration of drainage
liquid and label to be sent for wound
culture.
10 Provide physician needs for the incision.
11 Assist in drainage of wound.
12 Dress the wound using aseptic technique.
13 Document in the Nurses Notes the
procedure done.
C.ATTITUDE:
1 Explain the procedure to patient
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
2 Provide privacy by exposing only the site of
incision.
D.STAFF COMMENTS:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________

E.VALIDATORS COMMENTS:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________

F.PLAN:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________

G.REFERENCES:
1. Brunner and Suddarth's; Textbook of Medical Surgical Nursing 2006 (11th Ed.)
Lippincott William and Wilkins, Philadelphia.
2. Nettina et al; Manual of Nursing Practice, 2011 (9th Ed.) Wolters Kluwer Health/ Lippincott Williams and
Wilkins, Philadelphia.
3. Kozier and Erb; Fundamentals of Nursing Concept, Process and Practice, 2008 (8th Ed.) Prentice Hall Inc., New
Jersey.
NAME POSITION SIGNATURE DATE
ASSESSOR:
CANDIDATE
NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: Care of Closed Wound Drain.

Position Title: Staff Name: Unit: ID

No.:
COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Validators
WA = Written Assessment

Validation
Comment

Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 State the purpose of Closed Wound
Drain.
2 Knows the principle of sterile technique.
3 Identify the nursing responsibility based
on Hospital's policy of Restraints. care of
closed wound drain.
B.SKILLS:
1 Provide information to the patient about
drain.
2 Give psychological support.
3 Check the drain in situ or not.
4 Check the connection and patency of the
drain.
5 Multiple drains are numbered to record
reliably.
6 Check the type of fluid draining.
7 Maintain aseptic technique while
handling the drain.
8 Check the volume of the output.
9 Inform immediately if excessive drain is
noted.
10 Document in nurses notes the type of
drain, number of drains, output and type
of discharge.
C.ATTITUDE
1 Listens to patients complaints.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
2 Recognizes patient's ability and
limitations to movement.
3 Prevents the occurrence of infection.
D.STAFF COMMENTS:
________________________________________________________________________________________________
______________________________________________________________________________________________

E.VALIDATORS COMMENTS:
________________________________________________________________________________________________
______________________________________________________________________________________________
F.PLAN:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___________________________________________________________________________________________

G.REFERENCES:
Brunner and Suddarth's (2006). Textbook of Medical Surgical Nursing. (11th Ed.).Lippincott William and
Wilkins, Philadelphia.

NAME POSITION SIGNATURE DATE

ASSESSOR:
CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:Application of Dry Sterile Dressing

Position Title: Staff Name: Unit: ID
No.:
COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment
Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 State the purposes of dry wound
dressing.
2 Knows the principle of sterile technique.
3 Enumerate the different wound
assessment categories.
4 Enumerate the different equipments
needed for dressing.
B.SKILLS:
1 Check dressing set for expiry date.

2 Prepare complete equipment.

3 Inform and give clear instruction to
patient.
4 Prepare patient and provide privacy.

5 Place protective sheet at dressing site.

6 Wash hands.

7 Don gloves and mask.

8 Looses the tape towards the wound

dressing.
9 Remove and discard gloves.

10 Remove soiled dressing with forceps and

discard them appropriately.
11 Assess wound for color, consistency,
odor, size and presence of any drainage.
12 Open sterile dressing tray or set up
sterile supplies and cleansing solution.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment

Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

B.SKILLS:
13 Pour solution into sterile basin

14 Don sterile gloves.

15 Clean the wound with the cleaning solution

and gauze. Gauze may be held with the
forceps, or swabs may be used. Be sure to
cleanse from the area least contaminated to
the area more contaminated, and use a new
swab for each stroke. If there is a drain
present, cleanse this area last.
16 If a drain is present, apply precut dressing
around the drain. Apply a thick second layer
of gauze over the drain
17 Apply sterile dressing over wound.

18 Secure the dressing.

19 Remove, discard gloves and wash hand.

20 Place patient in comfortable position.

21 Document wound for: color, consistency,

odor and size.
C.ATTITUDE:
1 Introduces self, answers patients and
familys questions patiently and provide
complete information about the procedure.
2 Respects patients rights and accepts
behavior in response to the procedure.
3 Maintain aseptic technique throughout the
procedure.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

D.STAFF COMMENTS:
__________________________________________________________________________________________________
____________________________________________________________________________________________

E.VALIDATORS COMMENTS:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________

F.PLAN:
__________________________________________________________________________________________________
____________________________________________________________________________________________

G.REFERENCES:
De Laune, Sue and Ladner, Patricia (2002) Fundamentals of Nursing Standards and Practice, second edition. Delmar.
United States of America.

NAME POSITION SIGNATURE DATE

SSESSOR:

ANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
Competency Check List: STOMA CARE

Position Title: Staff Name: Unit: ID

No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Validators
Validation
WA = Written Assessment Comment

Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Define stoma.
2 State the importance of stoma care.
3 Enumerate care needed for patients with
stoma.
B.SKILLS:
1 Position the patient in supine and expose the
stoma site.
2 When changing the bag check for the size,
color, edge, and condition of stoma.
3 Observe for the amount, type, color and odor
of drainage.
4 Remove old bag carefully.
5 Clean stoma with normal saline in circular
motion with an inward stroke.
6 A piece of gauze may hold over the stoma
until new bag is attached.
7 Ensure that the hole made is accurately
measured against the stoma size.
8 Upon application of the new pouch, reassess
for any signs of allergy to adhesive wafer.
9 Record the output taken.
10 Document in the Nurses Notes care rendered.
C.ATTITUDE:
Explain the procedure to patient and family
1
tactfully.
Prepare the equipment completely prior to
2
procedure.
Provide privacy by exposing only the site of
3 stoma.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Encourage patient and relatives to express

feeling about stoma and recommend
4
counseling as needed.
Encourage pouch hygiene through rinsing,
5
keeping pouch tail free of stool.
6 Educate patient on how to control gases by
avoiding use of straws, excessive talking while
eating, chewing gum and smoking.
D.STAFF COMMENTS:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___________________________________________________________________________________________

E.VALIDATORS COMMENTS:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___________________________________________________________________________________________
_______________________________________________________________________________________________

F.PLAN:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___________________________________________________________________________________________
_______________________________________________________________________________________________

G.REFERENCES:
1. Brunner and Suddarth's; Textbook of Medical Surgical Nursing 2006 (11th Ed.)
Lippincott William and Wilkins, Philadelphia.
2. Nettina et al; Manual of Nursing Practice, 2011 (9th Ed.) Wolters Kluwer Health/ Lippincott Williams and
Wilkins, Philadelphia.
NAME POSITION SIGNATURE DATE
ASSESSOR:
CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: COLOSTOMY CARE (POUCH REMOVAL, CARE & POUCH
APPLICATION)
Position Title: Staff Name: Unit: ID
No.:

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment
Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Define Colostomy.

2 State the purposes of Colostomy Care.

3 Identify the nursing responsibility based

on Hospital's policy of Colostomy Care.
B.SKILLS:
1 Position patient in supine.

2 Place under pad near stoma.

3 Remove and discard the old pouch.

4 Clean the stoma area from outside inward

in circular motion with warm water and
soft tissue.
5 Assess the characteristic of stoma.
6 Allow skin to dry thoroughly.

7 Trace stoma pattern to appliance

adhesive pad 1.8mm larger than actual
stoma size, then cut.
8 Center the adhesive pad over the stoma
and gently press on the skin.
9 Gently press the pouch opening onto the
ring until it snaps into place.
10 Leave a bit of air in the pouch to allow
drainage to fall.
11 Apply the closure clamp.

12 Document in Nurse's Notes.

 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent
WA = Written Assessment

Assessors
Validation
Comment

Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

C.ATTITUDE:
Explain the procedure to patient and family
1
tactfully.
Prepare the equipment completely prior to
2
procedure.
3 Provide privacy at all times.
Assess patient's response to procedure and
4
give support.

D.STAFF COMMENTS:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
E.VALIDATORS COMMENTS:
_____________________________________________________________________________________________________
___________________________________________________________________________________________________

F.PLAN:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
____

G.REFERENCES:
1. Brunner and Suddarth's (2006). Textbook of Medical Surgical Nursing. (11th Ed.).Lippincott William and Wilkins,
Philadelphia.
2. Kozier and Erb (2008). Fundamentals of Nursing Concept, Process and Practice (8th Ed.) Prentice Hall Inc., New
Jersey

NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List:Colostomy Dilatation and Irrigation

Position Title: Staff Name: Unit: ID
No.:
COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment

Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Define Colostomy.
2 Enumerate purposes of Colostomy
Dilatation.
3 Enumerate purposes of Colostomy
Irrigation.
4 Identify the nursing responsibility based
on Hospital's policy of Colostomy
Dilatation and Irrigation.
B.SKILLS:
1 Explain the details of the procedure to
the patient.
2 Provide privacy and comfort.
3 Have the patient sit in front of the
commode on chair or the commode itself
4 Hang irrigating bag with prescribed
solution so the bottom of the bag is
approximately at the level of the
patient's shoulder and above the stoma.
5 Remove pouch or covering from the
stoma and apply irrigation sleeve,
directing the open tail into the commode.
6 Open tubing clamp on the irrigating bag
to release a small amount of solution into
the commode.
7 Lubricate the tip of the cone/catheter
and gently insert into the stoma.
8 Insert catheter no more than 3 inches
(7.5cm). Hold cone/shield gently but
firmly against stoma to prevent backflow
of water.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment

Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

B.SKILLS:
9 If catheter does not advance easily, allow
water to flow slowly while advancing
catheter. Dilating the stoma with lubricated,
gloved pinky finger may be necessary to
direct cone/catheter properly.
10 Allow water to enter colon slowly over a 5 to
10 minute period. If cramping occurs, slow
flow rate or clamp tubing to allow cramping
to subside. If cramping does not subside,
remove cone/catheter to release contents
11 Hold cone/shield in place 10 seconds after
water is instilled, then gently remove
cone/catheter from stoma.
12 As feces and water flow down sleeve,
periodically rinse sleeve with water. Allow
10-15 minutes for most of the returns. Then
dry sleeve tail and apply tail closure.
13 Leave sleeve in place for approximately 20
more minutes while patient gets up and
moves around.
14 When returns are complete, clean stomal
area with mild soap and water; pat dry;
reapply pouch or covering over stoma.
15 If applicable, the patient should use a pouch
until the colostomy is sufficiently controlled.
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment

Method
VA = Verbal Assessment

Date
Other Specify: .

C.ATTITUDE:
1 Introduces self, answers patients and familys
questions patiently and provide complete
information about the procedure.
2 Respects patients rights and accepts behavior
in response to the procedure.
3 Provide teaching and psychological support for
patient and family.
D.STAFF COMMENTS:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
E.VALIDATORS COMMENTS:
_____________________________________________________________________________________________________
___________________________________________________________________________________________________

F.PLAN:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
____

G.REFERENCES:
1. Brunner and Suddarth's (2006). Textbook of Medical Surgical Nursing. (11th Ed.).Lippincott William and Wilkins,
Philadelphia.
2. Kozier and Erb (2008). Fundamentals of Nursing Concept, Process and Practice (8th Ed.) Prentice Hall Inc., New
Jersey

NAME POSITION SIGNATURE DATE

ASSESSOR:

CANDIDATE NURSE:
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate

Competency Check List: Medication Administration & Review

COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Key on Left)

Competent

Assessors
Validation
WA = Written Assessment Comment

Method
VA = Verbal Assessment

Initial
Date
Other Specify: .

A.KNOWLEDGE:
1 Define medication

2 Type of medications order.

Pharmacokinetics.
Drug interaction.
Safe drug administration
3 Route of drug administration.
4 Identify the nursing responsibility based on
Hospital's policy of medication .
B.SKILLS:
1 Check medication on HMS and or physician
orders.
2 Identifies correct medication patient dose,
time, and route before administering
medication
3 Explain medication to patient /family
4 Administers medication by the route
ordered according physician order.
5 Charts all medication administered using
appropriate charting forms.
-Chart site of injection
-Chart accurate time of administration.
6 Demonstrate knowledge of reporting
adverse reactions to pharmacy and
physician
7 IV drip calculation.

8 Correct labeling procedure for IV tubing

9 Demonstrate correct IV push IV bolus

techniques .
 COMPETENCY ASSESSMENT CHECK LISTKingdom of Saudi Arabia
Ministry of health
General Nursing Directorate
COMPETENCY ASSESSMENT
VALIDATION METHOD KEY:
OB = observation

(Use evaluation
RD = Return Demonstration/simulated

Competent
Key on Left)

Assessors
Validation
Method
WA = Written Assessment

Initial
Date
Comment
VA = Verbal Assessment
Other Specify: .

C.ATTITUDE:
1 Introduces self, answers patients and familys questions
patiently and provide complete information about the
procedure.
2 Respects patients rights and accepts behavior in response
to the procedure.
3 Provide teaching and psychological support for patient
and family.

D.STAFF COMMENTS:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_______________
E.VALIDATORS COMMENTS:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_______________
F.PLAN:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_______________
G.REFERENCES:
1. Brunner and Suddarth's; Textbook of Medical Surgical Nursing 2006 (11 th Ed.)
Lippincott William and Wilkins, Philadelphia.
2. Nettina et al; Manual of Nursing Practice, 2011 (9th Ed.) Wolters Kluwer Health/ Lippincott Williams and Wilkins,
Philadelphia.
DAT
NAME POSITION SIGNATURE
E
ASSESSOR:

CANDIDATE NURSE: