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Departments & Programs,UW Health,Ambulatory Education,Ambulatory Orientation,Checklists - Core and Department Specific,Resources


Pulmonary - Departments & Programs, UW Health, Ambulatory Education, Ambulatory Orientation, Checklists - Core and Department Specific, Resources


PULMONARY CLINICAL TRAINING CHECKLIST ----- This is due three months from hire date------

Employee Name: __________________________________ Employee Credentials:________ Hire Date: ____________

Clinic Location/ number: _______________________ Employee Number ________________________

*** N/A on checklist indicates that it is not indicated for the employee***
*Refer to appropriate UWMF policy ***Each area should either be discussed or observed by preceptor***

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Employee is able to gather data relevant to the following:
Patient’s personal and family health history regarding pulmonary problem
Patient’s perception of current pulmonary problem and review current medications and

Onset of precipitating factors, to worsening symptoms or alleviating factors and timing
Accompanying factors to patient’s conditions (such as SOB or difficulty breathing )
Obtains vital signs* (Wt, Ht, BP, P, & Pulse ox), smoking history

S/S COPD – IE: assessment of asthma, Emphysema or Bronchitis (see below)
S/S ASTHMA - wheezing, prolonged expiration and dyspnea
S/S Emphysema - mild dyspnea on exertion, barrel-chest, accessory muscles (pink puffers)
S/S Bronchitis- chronic cough with sputum, intermittent wheezing, coarse crackles,

S/S New trach “problems”
S/S Lung Cancer - tachycardia, tachypnea, chest pain, hemoptysis, dyspnea, cough
S/S Sleep disorders/narcolepsy:
S/S Pneumonia – cough with sputum, fever, chest pain

Patient Education- Employee demonstrates knowledge & can discuss with patient:
Information on new medications and teaching medication administration
Demonstrate with placebos , MDIS spacers
Have patients view video tapes for flutter values
Lab results (WBC, Chemistry panel etc.)
Mails lab letter to patient (as directed by physician)
Able to elicit patient’s expectations in medical care and determine knowledge
level/deficit and ability to understand

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Able to identify cultural practices related to care-facilitate language lines or interpreters

Employee is able to appropriately care for a patient in the clinic with the following:
Receiving oxygen therapy (ensures pt’s portable tank is properly functioning) *
Receiving nebulizer treatments *
Lung Cancer (including end stage)
Sleep disorders/narcolepsy
ALS, myotonic dystrophy
RLS OSA patients using CPAP, BIPAP
TB (isolation room 10) appropriate use
Pertussis isolation
Trachs, assisting in changes of trach – suction of trach *

Surgery and other Admissions
Call admissions for direct hospital admit
Transport patient to assigned unit with appropriate paperwork

Consults/referrals to other departments or specialists.
Smoking Cessation Specialists, Social Services
Patient Relations
Physical Therapy, Occupational Therapy , Home Health, Hospice (DNR, DNI)
Speak with drug representatives, obtain samples appropriately

Demonstrate competence in counseling and provide appropriate resources
Diet, Smoking, Exercise
Domestic and Elder Abuse – Call patient relations if needed
Refer to specialty support groups
Obtain prior authorization for medications
Fill out forms for medications for those who need financial assistance (indigent drug


AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Procedures- Demonstrate competence to assist/set-up/patient care/follow-up
Trach changes
Spirometry (including calibration of machine)
Blood draws (obtains supplies) fills out appropriate paperwork, ABG’s (paperwork only)
Nebulizer treatment *
TB Test – form filled out, uses left forearm *
Administer IM adult, SQ adult, ID, & sublingual medications *
DEA Procedures/Controlled Substances Log and Controlled Substances Abuse *

Diagnostic/therapeutic tests- Demonstrate competence to assist/set-up/patient

Obtain Pulse Ox * including Resting and Exercise Pulse Ox, Titrate oxygen, Records on
appropriate forms

Obtain Sputum for culture, AFB cytology, complete lab encounter form
Obtain urine specimens *
Provide stool cards with explanations
Outside labs (Northwestern, Mira Vista)
Utilize lab binder to determine the correct lab tube to use (complete lab order form)
Utilize lab resources before sending specimens
Send specimens to correct lab
Proper and complete labeling of specimens and paperwork (in needed)
Basic Respiratory Care

Medication Administration: Understands compatibilities, side effects of the following

High dose inhaled corticosteroid with spacer chamber
Examples: Vanceil, Flovent, Advair, Pulmicort (bidesonide) & Azmacort

Systemic corticosteroids: Examples: prednisone tabs and medrol
Monoclonal antibodies group of drugs: Example: Xolair
Leukotriene modifiers tabs – Examples: Singulair, Zafirlukast, Accolate, Zyflo
Anticholinergics: Examples: ipratropium (Atrovent) tiotrepium (Spiriva)
Oral beta 2 agonist: Example: Theophylline
Short acting beta 2 agonists: Examples: Albuterol, Maxair, Proventil, Ventolin, Xopenex
Long Acting beta agonists: Examples: Serevent, Foradil
Flu vaccine
Anti-neoplastic: Example: methotrexate


AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Complete the TB CBT in LDS titled “TB Skin Test Administration and Reading”.
Properly perform TB testing and reading – new employee to demonstrate this skill twice for
another staff person (preceptor’s initials) ___________, ____________

HealthLink Training
Medication and Test Orders
IMM’s and Injections
Anticoagulation Training
Prior Authorization for Xolair


I, _________________________________________ (employee name) have completed the Pulmonary Training Checklist and attest the
information is true and valid. I have demonstrated or discussed these skills and I am responsible for performing patient care as a Certified Medical
Assistant / Licensed Practical Nurse / Registered Nurse (circle one).

__________________________________________________ ___________________
Preceptor Date

____________________________________________________ ___________________
Supervisor Date

__________________________________________________ ___________________
Provider Date

Additional Preceptor Signatures/initials:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________

Initially Completely 02-17-04, Updated 8/05, 1/06, 7/07, 9/11, 3/12, 3/14, 6/14, 3/15

 Send the original signed Clinical Training Checklist to Clinical Staff Education - 414.
 One copy of the signed Clinical Training Checklist should be placed in the clinic’s staff employee’s file, and a copy given to the employee.

Brener, T., Doyle, R.M. (Ed.). (2008). Nursing 2008 drug handbook. Philadelphia, PA: Lippincott Williams & Wilkins.
Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5th ed.). St. Louis, MO: Mosby.

Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.