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

Wisconsin Sleep Center

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


WISCONSIN SLEEP, INC. 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: (per Ref #3)
Patient’s perception of current sleep problem and review current medications,
including OTC and medication start dates, and dosages. Review Allergies.

Onset of precipitating factors, to worsening symptoms or alleviating factors and

Accompanying factors to patient’s conditions (such as OSA, RLS, PLMD,
Narcolepsy, Insomnia, etc…)

Obtains vital signs* (Wt, Ht BP, P, Pulse ox)
Obtain social history to include tobacco and substance abuse and occupational

S/S SDB - IE: assessment of OSA
S/S Narcolepsy- IE: assessment of hypersonmnolence
S/S RLS/PLMD- IE: assessment of these disorders
S/S Insomnia- IE: assessment of sleep difficulties/behavior
S/S Pediatric Sleep disorders

Patient Education- Employee participates in patient/family teaching.
Patient education materials available in Nursing Station and Exam Rooms.

Information on new medications and teaching medication administration IE:
stimulants, sleepers, etc..

Demonstrate knowledge of CPAP, BIPAP, and AUTOPAP equipment
Lab results (CBC, TSH, Glucose, LFT’s 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

Able to identify cultural practices related to care-facilitate language lines or

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Employee is able to appropriately care for a patient in the clinic with the

Receiving oxygen therapy (ensures pt’s portable tank is properly functioning)
Sleep Disordered Breathing patients using CPAP, BIPAP, AUTOPAP
Narcolepsy/Hypersomnolence patients on stimulants
RLS/PLMD patients on medication therapy
Pediatric patients with sleep disorders

Consults/referrals to other departments or specialists.
Phone Numbers located in Nursing Station.

Smoking Cessation Specialists, Social Services
Patient Relations
Home Health Referral (CPAP, BIPAP, AUTOPAP)
Psych Referral
ENT Referral
Dental Specialist

Demonstrate competence in counseling and provide appropriate resources
Diet, Smoking, Exercise
Domestic, Elder, and Child Abuse – Call patient relations if needed

Obtain prior authorization for medications and the forms designated for each
insurance carrier.

Fill out forms for medications for those who need financial assistance (indigent
drug program)- Call Patient Resources for assistance if needed.

Procedures- Demonstrate competence to assist/set-up/patient care/follow-up

Phlembotomy: obtains lab order form and supplies, prepares and authenticates
pt, fills out appropriate paper work, performs phlebotomy, appropriately handles
blood samples

Proper and complete labeling of specimens and paperwork (in needed)
EKG pad placement

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Drug Refills-Demonstrates competence to assist/set-up/patient care/follow-

Utilizes protocol to address Rx requests for refill
Communicates with patient/pharmacy regarding refill request
Communicates with providers if needed regarding refill request
Records all action in log/telephone messaging/EPIC notes

Medication Administration Understands compatibility’s, side effects of the
following medications:

Nasal steroids, nasal antihistamine spray
Dopaminergic agonists
Nonbarbituate hypnotics
Psychomotor stimulants


I, _________________________________________ (employee name) have completed the WI Sleep Clinical 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 Completed: 10/07; updated 9/2011, 3/2012, 7/2014, 3/2017

 Send the original signed Clinical Training Checklist to Clinical Staff Education – 1035.
 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. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.