Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
    		•
    AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (1 month to 1 year)
    Toddler (1 year to 3 years)
    Preschooler (3 years to 5 years)
    School Age Child (5 years to 12 years)
    Adolescents (12 years to 18 years)
    Young Adults (18 years to 39 years)
    Middle Adults (39 years to 64 years)
    Older Adults (64 years to 79 years)
    Elderly Adults (over 79+ years)
    SKILLED ENVIRONMENTS
    Acute Care/ Hospital
    Managed Care
    SNF/ Long Term Care
    Home Health
    Outpatient
    GENERAL RISK/QUALITY
    Electronic Documentation
    Written Communication Skills
    Verbal Communication Skills
    Basic Negotiation Skills
    Job Related Computer Skills
    Ability to Prioritize
    Ability to Properly Maintain Records
    Interpret and Implement Quality Assurance Standards
    Review Existing Policies and Procedures
    Write Quality Assurance Policies and Procedures
    Ability to Work Effectively in All Situations
    Review and Evaluate Medical Records
    Ability to Gather Data, Compile Statistical Information and Prepare Reports
    Review Patient Record to Determine Need for Continued Stay
    Coordinate and Monitor Services, Including Comprehensive Tracking of Client Activities in Relation to Care Plan
    Document All Client Encounters
    Identify and Provide Emergency Crisis Services as Necessary
    Ability to Develop and Implement Action Plans for Health Centers to Improve Performance
    Strategic Thinking
    Ethical Judgment
    EXPERIENCE
    Reviewing Facility Policy and Procedures
    Knowledge of State Protocols/Regulations
    Risk Analysis
    Insurance Knowledge
    Vendor Relations
    Identify Threats and Emerging Risk
    Identify, Assess, Mitigate and Evaluate Risk
    RCA Facilitation
    Accredidation Survey Preparation
    Grievance Process
    Incident Reporting and Follow-up
    Conflict Resolution
    Emergency Medical Treatment and Active Labor Act (EMTALA)
    HIPAA and Patient Rights
    Staff Roles and Responsibilities
    Financial Management
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    Knowledge of Oasis
    Knowledge of CMS