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/depts/uwhealth/ambulatory-education/checklists/resources/Peds_Checklist.pdf

20170367

page

100

UWMF,

Learning and Development,

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

Pediatrics

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




1
CORE COMPETENCIES
PEDIATRICS CLINICAL TRAINING CHECKLIST ----- This is due two months from hire date------

Employee Name: __________________________________ Employee Title: __________________________ Hire Date: ____________

Clinic Location/ number: ____________________________Employee Number ________________________

*use appropriate UWMF polices *** N/A on checklist indicates that it is not indicated for the employee***
AREA OF ORIENTATION Discussed/
Observed
(D/O)
Preceptor’s
Initials
Completed
date
Educational resource
Immunization Education Part 1: To be completed within two weeks of start date
Online Learning and Development System (LDS) Course: UW Health Immunization
Education course include the following: (1-9 below)

1. Vaccine Adverse Event Reporting System (VAERS)- website (http://vaers.hhs.gov/index) – view
VIDEO: An Overview of VAERS: 10-minute video (review only)

2. Patient Safety Net (PSN) training as related to immunization errors – (CBT review only)
3. CDC; Understanding the Basics: General Recommendations on Immunization:
4. ( a minimum of one hour to complete)

5. It’s federal law! You must give your patients current Vaccine Information Statements (VIS)
6. How to administer IM and SQ injections to Adults
7. How to administer Intramuscular (IM) and Subcutaneous (SQ) injections (infants/toddlers)
8. Administering Vaccines: Dose, Route, Site, and Needle Size
9. Administering Vaccines: IM, ID and intranasal
10. Administering Vaccines: oral
Complete the below onsite with manager, team leader or nursing supervisor
1. Wisconsin Immunization Registry (WIR) training
2. Vaccine Storage Information (immunize.org) – per organizations policy
3. Wireless Temperature Monitoring (as applicable to clinic/department)
4. Current VIS sheets for all immunizations – given at the assigned clinic
5. Multi dose vial use – initial and date when opened
6. Screening questions for parent/guardian – UW Health created forms
7. Current CDC immunization schedules – all age groups appropriate for practice
8. UW Health simple immunization schedule grid for pediatric patients
9. Health Facts For You (HFFY) # 6835 “Non-drug Pain Control for Kids” (11.2012)
10. Parental consent for immunizations – verbal permission documented in patient’s chart / minor’s
right to consent for HPV (contraceptive care)

Complete the below during orientation by educator, CNS or Preceptor/Nursing
Supervisors/Team Leader

1. UW Health Immunization Procedures Delegated Protocol – Outpatient
2. UW Health Vaccine Refusal Policy



2
AREA OF ORIENTATION (D/O) Preceptor’s
Initials
Completed
date
Educational resource
Immunization Competency Validation Part 2: Complete immunization
administration competency checklist within 2 weeks of employment – onsite
with preceptor or designated other

1. Staff person reconciles correct patient’s WIR sheet with HealthLink immunization record and
verifies vaccinations needed

2. Staff person provides screening questionnaire to patient or guardian and reviews results
3. Staff orders immunization(s) as indicated per protocol
4. Staff provides necessary VIS sheet(s) to parents/patient/guardian for review and educate on the
possible side effects and/or reactions

5. Staff performs Hand Hygiene and selects proper vaccine, equipment and prepares ordered
immunizations -- Needle length (per CDC), demonstrate or discuss proper diluents used, how to
properly reconstitute & labeling of syringe if reconstituting

6. Staff performs the “5 Rights”; include exp. date on vial/syringe & patient’s DOB
7. Staff enters exam room and verifies correct patient using at least two patient identifiers; name,
date of birth or telephone number may be used

8. Staff verifies immunizations to be given with patient/parent/guardian
9. Staff performs Hand Hygiene, glove, and selects appropriate site(s) and route for immunizations
ordered (demonstrates giving of injection(s)) -- per CDC recommendations

10. Staff recommend patients wait 15 minutes in order to observe for any untoward reaction
11. Staff provides patient or guardian an updated immunization record – WIR, MyChart, AVS
(.imm), or other form of documentation

12. Staff completes documentation in HealthLink; utilize .npwimmscreen smart phrase and
Immunization smart set

Online Training: utilize the Learning and Development system (LDS)
LDS Course name:
Depo-provera Injection Training for new staff – to be completed by any staff person who will be
administering Depo-provera.

Complete the ENT CBT in LDS titled “Ear, Nose and Throat Skills Toolkit (CSE ENT)”
Complete the SBAR CBT in LDS titled “CSE SBAR”
Well child – (Provide copies of Bright Futures handouts to new employee)
0-3 months of age
3months - 2 years
2-4 years
4-7 years
4-10 years
10-12 years
12+ years
Documentation of sports pre-participation questionnaire in Healthlink
Employee is able to obtain the following
Patient assessment procedures and screenings:
ξ Oral Temperature (if used in clinic)
ξ Ear Temperature (if used in clinic)



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ξ Axillary Temperature (if used in clinic)
ξ Pulse Rate – radial and apical*
AREA OF ORIENTATION (D/O) Preceptor’s
Initials
Completed
date
Educational resource
ξ Respirations*
ξ Blood Pressure*
ξ Orthostatic BP and P*
ξ Pulse Oximeter*
ξ Peds to Adult Weight/Height*
ξ Infant weight/length/Head circumference*
ξ Hearing screening –
ξ Vision screening – explains norm/age: Visual changes through the life span – Age 3
(20/40), Age 5 (20/30), Age 7 (20/20)

Screenings – Employee can explain to parent(s) or provide handouts:
Why newborns are screened for several screens such as tryosinemia, CF, toxoplasmosis etc.
Lead screening for high risk children begins at 6 months
Cholesterol whose parents are > 240 mg/dl
Anemia may be recommended for some high risk children
Dental – routine care for all children – sealants and fluoride
Reach Out and Read Program
Describe the following screening tools: at what ages, how to score, and where they are filed in
Healthlink
ξ ACT - understands to confer with MD as to who scores and enters into Healthlink, when to
administer, and to which patients to administer
ξ MChat – 18 and 24 months
ξ ASQ – 9, 18, 24, and 30 months

Knowledge and scoring of postpartum depression screening, conferring with provider at what ages
to give the postpartum depression screening

Violence screening
Urine screening can be recommended during school age and once during adolescence
Urine screening if recommended: includes - glucose, protein, RBC, WBC, and bacteria
Basic Office visit data collection will include the following: refer to PCR Package 1
checklist as applicable to clinic

Collect reason for visit and short summary of chief complaint (use of .nn smart phrases)
Obtain all necessary vital signs – i.e. BP, Pulse, Respirations, in alignment with UWMF policies*
Review current drug list with patient- document any changes and pharmacy choice
Review current allergy list- document any changes
Employee is able to gather information and document the following:
Patient/parental/teen concerns
Interval History - recent illness, accidents, consults and how to access in Chart Review
Feeding/Nutrition - feeding patterns, food preferences, food allergies/intolerance, water source, WIC
program

Dental - sees dentist, brush/floss



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Elimination/GI/GU - constipation, diarrhea, urinary, menstruation
Sleep - Bedtime routine, naps, total hours sleep, sleep problems
AREA OF ORIENTATION (D/O) Preceptor’s
Initials
Completed
date
Educational resource
Social/Family situation - Lives with, medical coverage, childcare situation, changes, stressors,
violence ( EPDS in Healthlink, Domestic Violence questionnaire)

School-grade - attendance, achievement, activities, peers
Language – i.e. following commands, and simple reasoning
Fine motor – i.e. scribbling, removing clothes, using a fork or blocks
Gross Motor - walks well climbs throws balls, jumps, starting to run
Preschooler - 4 to 5 years /psychosocial – initiative vs guilt by the following:
Sensorimotor - i.e. magical thinking or symbolic play, concepts of hungry tired, cold
Language – i.e. recognizing colors, action words, or asking questions, counting
Fine motor – i.e. cutting with scissors, dressing self, drawing people and shapes
Gross motor - i.e. pedaling tricycle, balancing on one foot, catching ball, hops on one foot
School age - children 6 to 11 years /psychosocial – industry vs inferiority
Sensorimotor - concrete thinking, relation and ordering
Language – i.e. asking for help, is moving beyond simple concepts, responsibility for health
Fine motor - i.e. participation in daily exercise and hobbies such as piano or karate
Gross motor - i.e. participation in organized sports/others may shy away from group activities
Anticipatory Guidance: Employee is given resources as future reference
Nutrition- Infants – Employee is able to or determine:
Gather data on breast feeding or the use of standard infant formula and lacto-free formula
Discuss feeding techniques with mother (if breastfeeding) Understands use of Lactation consultant
Review formula intake with parent(s) - (average 24 or 32 ounces per day)
Advise that infants to start on spoon between 4 to 6 months old
Advise to introduce 1 food every 3 to 4 days starting with1 tablespoon of iron-fortified rice cereal -
(unless suggested otherwise by provider) or as tolerated by baby

Advise advancing 1/3 cup and ½ cup total divided into 2 feedings.
Advise advancing to 3 to 4 tablespoons of fruits and vegetable per day to one year of life(unless
suggested otherwise by provider)

Advise fruit juice should be limited to 4oz/day at 6 months of age (unless suggested otherwise by
provider )

Advise early introduction of solid foods may increase risk of allergies
Advise a cup at 6 to 9 months and whole cow’s milk at 1 year, NO HONEY, CITRUS AND EGG
until 1 yr

Advise to avoid nuts, popcorn, hot-dogs, grapes, hard candy, potato chips to avoid choking
Advise no whole eggs, egg whites or peanut products, peanut oil, citrus, seafood until 1 yr.
Nutrition – Toddler - Employee is able to:
Include foods from 5 major food groups, offer 3 meals and 3 snacks/ day
Advise parents that appetites will drop between 12-15 months



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Nutrition – Preschooler - Employee can explain that:
Physical growth rate decreases as a child grows.
AREA OF ORIENTATION (D/O) Preceptor’s
Initials
Completed
date
Educational resource
Milk intake decreases to 16-24 ounces per day, & children should be offered 3 meals & 2 snacks per
day

Elimination – Infant- Employee can explain:
Usually stool after feedings, breastfed-softer stools, yellow seedy stools, formula-fed more Pasty
stools

Urinate 6 to 7 times in 24 hours
Elimination – toddlers- Employee can explain:
Toddlers are “usually” ready to toilet train between 24 to 36 months
Toddlers urinate 8 to 14 times in 24 hours
Daytime control is accomplished before night time control
Sleep- Infant- Employee can explain to a new parent(s):
A 6 month infant can sleep 6 to 8 hrs, and a total for 10 to 15 hrs per day
A 6 to 12 months infant can sleep 8 hrs, and a total for 10 to 15 hrs per day
Advise parents not to leave infants unattended on adults beds, children should sleep in their own
beds

Supine is best “back” to bed, avoid soft mattresses and overheating of the infant. Avoid waterbeds.
Sleep- Toddler- Employee can explain to parent(s):
Total sleep time is 10 to 12 hours per day, including one nap, bed ritual important
Nightmares and night terrors a common problem
Child needs to be moved to youth bed, if beginning to climb out of crib (important safety issue)
Sleep- Preschooler - Employee can explain to parent(s):
Total sleep time 8 to 10 hours per day, maybe one nap, bed ritual important
That nightmares may still a problem, but night terrors less of problem
Sleep- School age - Employee can explain to parent(s):
That total sleep time 8 to 10 hours per day
Child with Sickle Cell Disease
Can obtain information via the Sick Cell website www.sicklecelldisease.org
Can give patient and parent patient education regarding infection control
measures, temperature taking, getting the flu vaccines etc.
Medications, behavior issues, increasing fluids, symptom recognition and
control, rehabilitation, pain issues

Child with Asthma – Types of medication given for asthma
Quick Acting Medications: Albuterol (generic, Ventolin, Proventil)
*a beta-agonist used for acute symptoms (SOB, cough, wheezing)

Quick Acting Medications: Ipatropium (Atrovent)
*an anti-cholinergic used for acute symptoms (SOB, cough, wheezing)

Controller Medications: Inhaled Corticosteroids (Flovent, Pulmicort, Aerobid)
*used for chronic therapy to stabilize and maintain good asthma control




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Long-Acting Beta-Agonist (Serevent)
*used for chronic therapy to stabilize and maintain good asthma control

AREA OF ORIENTATION (D/O) Preceptor’s
Initials
Completed
date
Educational resource
Combined Medications (Advair = Flovent + Serevent)
*used for chronic therapy to stabilize and maintain good asthma control

Leukotriene Antagonists - (Singulair, Accolate) *a modifier of inflammatory mediators
Oral steroids – (Prednisone)
Spacers and MDI’s - understands spacers and MDI’s
Child with ADHD – Attention Deficit Hyperactivity Disorder
Obtain feedback from parents, other family members (when appropriate) and teachers (when
appropriate)

Vanderbilt Teacher and Parent Informant questionnaires
Employee can discuss with patient / parent(s) the following medications:
Ritalin, Dexedrine, Adderall, Merapex, Clorazepam, Strattera:
Side effects – stomachache, decreased appetite, headache, increased heart rate/BP, Tics,
irritability, sleep difficulties and slowing of growth
Ritalin rare effects of neutropenia, thrombocytopenia, eosinophilia

Antihypertensive agents clonidine (catapres) and guanfacine (Tenex) can treat the over activity and
impulsivity (will most often be prescribed by specialist, not by pediatrician)

Tricyclic antidepressants: _____________________ can improve mood and decrease hyperactivity
(will most often be prescribed by specialist, not by pediatrician)

National Organization for ADHD 1-800-233-4050 or www.chadd.org
Administration of Medications/Vaccines:
Appropriately performs TB testing and reading* – employee shall demonstrate this skill at least twice
for another staff person:_______, ________ (preceptor’s initials in blanks)

Administer allergy shots*– employee shall demonstrate this skill at least twice for another staff
person. (if applicable) _______, ________ (preceptor’s initials in blanks)

Medication Adm. - employee will demonstrate a minimum of two injections per category listed below
using the corresponding UWMF policy. Preceptor will initial blank when completed.

o Adult or child: intradermal* _________ & __________
o Adult >18 years: subcutaneous* _________ & __________
o Adult >18 years: intramuscular* _________ & __________
o Child 5-17 years: subcutaneous* _________ & __________
o Child 5-17 years: intramuscular* _________ & __________
o Infant 0-5 years: subcutaneous* _________ & __________
o Infant 0-5 years: intramuscular* _________ & __________
Employee demonstrates a knowledge of administering medication via the following routes:
 Oral*
 Rectal*
 Eye drops/ointment*
 Ear drops*

Knowledge of DEA procedures/Controlled Substances Log
Review process for medication errors
Employee understands the UWMF policy of drawing up a medication
from a vial and labeling the syringe*




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Medication Refills:
AREA OF ORIENTATION (D/O) Preceptor’s
Initials
Completed
date
Educational resource
Properly refills medication according to clinics or provider’s protocol – review .rfp smart phrases if
applicable

Forms - Employee is able to demonstrate ability to use Healthlink forms as available.
Demonstrates competence in completion of day care, camp, and school medication forms in
Healthlink, WIAA Cards, and prescriptions for various therapies

Demonstrates competence in obtaining a verbal consent from a parent for treatments of minors
Ordering Procedures: - Employee is able to:
Demonstrates competence in arranging for procedures ordered by provider and completing
appropriate paperwork and forms.

Telephone Calls – Employee is able to:
Registered Nurse Staff: Conduct telephone triage; assessing patient’s and parent’s concerns and
provides the best disposition for the situation.
*Team Leader review documentation of 10 triage calls within first month looking for completeness,
disposition, and documentation. Discuss UWMF Co sign policy as it relates to RN staff.

Licensed Practical Nurse / MA staff (either MA/CMA/RMA):
Conduct telephone message taking to best relay patient’s and/or parent’s concerns. Discuss UWMF
Co sign policy as it relates to MA/LPN staff.

Demonstrates knowledge of telephone call documentation requirements; use of ‘smart phrases’
Triage resources: Has knowledge of resources appropriate for the age population
ξ Barton Schmitt Pediatric triage book,
ξ External Resources available on HealthLink and Health Facts for You documents on
UConnect.

Review HIPPA and telephone calls; leaving a voice message
Conduct call backs in same half day or sooner if possible
Properly refills medication per telephone call according to protocol
Demonstrates competence in counseling and provides appropriate resources
Registered Dietitian, Diabetes Educators, Gestational
Psych-mental health, Fitness and Exercise, New Start, Other UWMF Clinics
Knowledge of “Family binder” (East Towne only)
Expedited Partner therapy
Equipment/ Supplies - Employee is able to:
Assure all equipment/supplies are available based on patient needs
Assure all equipment functions before use
Cleaning rooms and stocking items
Procedures- Demonstrate competence to assist/set-up/patient care/follow-up in
both pediatric and adult populations as appropriate:

Fit and apply orthotic device(s):
Examples include: ace wrap, wrist/finger splint, shoulder immobilizer,
cervical collar, sling, rib belt, air cast

Fit patient for crutches, provide instructions*
Suture/ Staple removal
Ear flushing*



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Eye flushing
AREA OF ORIENTATION (D/O) Preceptor’s
Initials
Completed
date
Educational resource
Nebulizer treatments*
Using spirometry
Tympanogram
Wart Removal
Nose Bleeds
Patient instruction in MDI/ spacers/ peak flow
Assist with laceration repair
Assist with performing burn care
Urine catheterization *
Enemas *
Fluoride varnish application
Surgery – Employee is able to:
Schedule surgery of patients appropriately- discuss process with parent(s)
Check for pre-authorizations
Employee is able to provide basic appropriate URGENT patient care
Respiratory Emergency in pediatric patients
ξ Check if patient is using accessory muscles
ξ Check if patient is using the Orthopneic position (patient is sitting up and bent forward with
the arms supported on a table or chair arms).
ξ Check if patient has nasal flaring

Understand the crash cart set-up & contents- including medications and defibrillator
Requiring CPR; to include bag mask device
Oxygen administration
Fainting (syncope) policy
Knowledge of 6 Emergency Protocols
Stocks the crash cart appropriately (if applicable)
Perform appropriate daily crash cart ‘checks’ (if applicable)
UWMF Initiatives or other established procedures:
My Chart Program – through UW Health
Health Maintenance
Reporting Workbench Training – MA/LPNs and RNs
Motivational Interviewing I and II Training for RNs










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AREA OF ORIENTATION (D/O) Preceptor’s
Initials
Completed
date
Educational resource
Other areas of understanding, as required, based on clinic location:











I, _________________________________________ (employee name) have completed the Core Competency 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).

__________________________________________________ ___________________ Additional Preceptor Signatures/initials:
Manager Date
1.___________________________
____________________________________________________ ___________________
Nursing Supervisor Date 2.___________________________

__________________________________________________ ___________________ 3.___________________________
Lead Physician or Clinic Medical Director Date

Initially Competed 10-10-02 Updated 9.2011, 3.2012, 10.2013, 4.2014 02.2016, 6.2016, 7.2016, 8.2016, 11.2016, 3.2017

 Send the original signed Core Competency Checklist to Clinical Staff Education - 1035 within two months from hire.
 One copy of the signed Core Competency Checklist should be placed in the clinic’s staff employee’s file, and a copy given to the employee.

REFERENCES:
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.