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Adult Non-Rebreather Evaluation

Name(Required)







Equipment and Patient Preparation

Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable

Patient Evaluation

Satisfactory
Unsatisfactory
Not observed
Not Applicable

Implementation of Procedure

Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable

Follow-up

Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable

Demonstrates Knowledge of Fundamental Concepts

Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable

Clinical Competency Performance Criteria

Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable
Satisfactory
Unsatisfactory
Not observed
Not Applicable

Summary performance evaluation

Please use the following criteria and select the appropriate pop-up menu.
Satisfactory - ready for clinical application with minimal supervision. Performed procedure accurately, or was able to correct performance without injury to the patient or decreasing effect of therapy being given.
Unsatisfactory performance - not ready for clinical application. Requires remediation under one of the following categories
Minor - Unsatisfactory: Needs to review fundamental concepts or requires re-evaluation of minor deficiency(s) (ex. forgets to wash hands during the Follow-up stage. Must be re-evaluated on this step not the whole procedure).
Major - Unsatisfactory: Requires additional supervised clinical practice and complete re-evaluation of the procedure
Satisfactory
Minor - Unsatisfactory
Major - Unsatisfactory

References

1.AARC Clinical Practice Guideline: "Oxygen Therapy in the Acute Care Facility – 2002 Revision & Update" RC 2002;47:(6) p717-720
2.CDC, Guideline for Hand Hygiene in Healthcare Settings. MMWR Oct. 25, 2002; vol. 51(No. RR-16)
3.Mahler, D; Weinberg D, Wells C, and Feinstein A. The measurement of dyspnea: contents, interobserver agreement and physiologic correlates of two new clinical indexes. Chest 1984; 85:751-758
4.Joint ACCP/AACVPR Pulmonary Rehabilitation: Evidenced-Based Guidelines Chest 1997; 112:1363-1396
5.Branson R.D.; Hess D.R.; Chatburn, R.L.: "Respiratory Care Equipment" Lippincott 2nd, 1999 p75