Oncology Competency Self Assessment

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Oncology Competency Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date Settings Inpatient oncology unit 0 1 2 3 4 5 Outpatient oncology unit 0 1 2 3 4 5 Hospice/palliative care 0 1 2 3 4 5 Participation in support groups 0 1 2 3 4 5 Death & dying counseling 0 1 2 3 4 5 General Skills Awareness of HCAHPS 0 1 2 3 4 5 Advanced directives 0 1 2 3 4 5 Patient/family teaching 0 1 2 3 4 5 Restrictive devices (restraints) 0 1 2 3 4 5 Lift/transfer devices 0 1 2 3 4 5 Specialty beds 0 1 2 3 4 5 End of life care/palliative care 0 1 2 3 4 5 Automated Medication Dispensing System, Pyxis, Omnicell, or other 0 1 2 3 4 5 Bar coding for medication administration 0 1 2 3 4 5 National Patient Safety Goals 0 1 2 3 4 5 Accurate patient identification 0 1 2 3 4 5 Effective communication 0 1 2 3 4 5 Interpretation & communication of lab values 0 1 2 3 4 5 Medication administration 0 1 2 3 4 5 Labeling 0 1 2 3 4 5 Anticoagulation therapy 0 1 2 3 4 5 Reconciliation 0 1 2 3 4 5 Monitoring conscious sedation 0 1 2 3 4 5 Pain assessment & management 0 1 2 3 4 5 Use of PCA (IV, intrathecal, epidural) 0 1 2 3 4 5 Infection control 0 1 2 3 4 5 Universal precautions 0 1 2 3 4 5 Isolation 0 1 2 3 4 5 Minimize risk for falls 0 1 2 3 4 5 2015 Medical Staffing Network Rev. 06/15 F01202 Oncology 1 of 7

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) General Skills - cont. Prevention of pressure ulcers 0 1 2 3 4 5 Wound care 0 1 2 3 4 5 Cardiac Monitoring & Emergency Care Obtains 12 lead EKG 0 1 2 3 4 5 Interpretation of rhythm strips 0 1 2 3 4 5 Treatment of dysrythmias 0 1 2 3 4 5 Use of rapid response teams 0 1 2 3 4 5 Cardiac arrest/cpr 0 1 2 3 4 5 O2 therapy & delivery 0 1 2 3 4 5 Pulse oximetry 0 1 2 3 4 5 Use of doppler 0 1 2 3 4 5 IV Therapy Starting & maintaining peripheral IVs 0 1 2 3 4 5 Blood draw: venous 0 1 2 3 4 5 Central line care 0 1 2 3 4 5 Blood draw: central line 0 1 2 3 4 5 Care & management of ports 0 1 2 3 4 5 Care & management of PICC/Groshong/Hickman 0 1 2 3 4 5 TPN & lipids 0 1 2 3 4 5 Administration of blood/blood products 0 1 2 3 4 5 Administration of chemotherapy 0 1 2 3 4 5 Continuous infusion 0 1 2 3 4 5 IV push 0 1 2 3 4 5 Oral 0 1 2 3 4 5 Monitoring chemotherapy (does not initiate) 0 1 2 3 4 5 Other Diabetes mellitus 0 1 2 3 4 5 Blood Glucose Monitoring (BGM) 0 1 2 3 4 5 Insulin administration 0 1 2 3 4 5 Cardiovascular Cardiac assessment 0 1 2 3 4 5 Care of Patient with: CHF 0 1 2 3 4 5 Cardiac disease (CAD/MI/post CABG) 0 1 2 3 4 5 Hypertension 0 1 2 3 4 5 Pacemakers 0 1 2 3 4 5 2015 Medical Staffing Network Rev. 06/15 F01202 Oncology 2 of 7

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Respiratory Ascultation of breath sounds 0 1 2 3 4 5 Chest PT 0 1 2 3 4 5 Tracheostomy care 0 1 2 3 4 5 Oral or nasotracheal suctioning 0 1 2 3 4 5 Assist with chest tube insertion & management 0 1 2 3 4 5 Assist with thoracentesis 0 1 2 3 4 5 Care of Patient with: Asthma 0 1 2 3 4 5 COPD 0 1 2 3 4 5 Pneumonia 0 1 2 3 4 5 Tuberculosis 0 1 2 3 4 5 GI/GU NG tube insertion 0 1 2 3 4 5 Long term feeding tube insertion (Dobhoff/Keofeed) 0 1 2 3 4 5 Care of the patient with enteral feedings 0 1 2 3 4 5 Gastrostomy tube 0 1 2 3 4 5 Jejunostomy tube 0 1 2 3 4 5 Colostomy & enterostomal care 0 1 2 3 4 5 Ileostomy 0 1 2 3 4 5 Peritoneal dialysis 0 1 2 3 4 5 Hemodialysis 0 1 2 3 4 5 Care of shunts & fistulas 0 1 2 3 4 5 Nephrostomy tube 0 1 2 3 4 5 Suprapubic catheter 0 1 2 3 4 5 Foley catheter insertion & management 0 1 2 3 4 5 Neuro Comprehensive neuro assessment 0 1 2 3 4 5 Seizure precautions 0 1 2 3 4 5 Care of Patient with: Post neuro surgery 0 1 2 3 4 5 TIA/CVA 0 1 2 3 4 5 Degenerative neurological disorders 0 1 2 3 4 5 2015 Medical Staffing Network Rev. 06/15 F01202 Oncology 3 of 7

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Oncology Specific Care Assist with bone marrow biopsy 0 1 2 3 4 5 Immunosuppression/laminar airflow 0 1 2 3 4 5 Administration of chemotherapy 0 1 2 3 4 5 Use & Administration of the Following: Fluorouracil (5-FU) 0 1 2 3 4 5 Doxorubicin (Adriamycin) 0 1 2 3 4 5 Methotrexate (amethopterin) 0 1 2 3 4 5 Mitomycin (Mutamycin) 0 1 2 3 4 5 Bleomycin (blenoxane) 0 1 2 3 4 5 Hydroxyurea (Hydrea) 0 1 2 3 4 5 Melphalan (Alkeran) 0 1 2 3 4 5 Usulfan (Myleran) 0 1 2 3 4 5 Etoposide (VP-16-213) 0 1 2 3 4 5 Cistplatin 0 1 2 3 4 5 Vinblastine (Velban) 0 1 2 3 4 5 Vincristine (Oncovin) 0 1 2 3 4 5 Cyclophosphamide (Cytoxan) 0 1 2 3 4 5 Avastin 0 1 2 3 4 5 Taxol 0 1 2 3 4 5 Herceptin 0 1 2 3 4 5 Carboplatin 0 1 2 3 4 5 Taxotere 0 1 2 3 4 5 Oxaliplatin 0 1 2 3 4 5 Dilantin 0 1 2 3 4 5 Corticosteroids 0 1 2 3 4 5 Decadron 0 1 2 3 4 5 IVIG 0 1 2 3 4 5 Epogen/neupogen 0 1 2 3 4 5 Biotheraputic agents (Rituxan) 0 1 2 3 4 5 Care of the Patient Pre & post Bone Marrow Transplant (BMT) 0 1 2 3 4 5 BMT patient care 0 1 2 3 4 5 Patient & donor education 0 1 2 3 4 5 Peripheral blood stem cells 0 1 2 3 4 5 Solid tumors 0 1 2 3 4 5 Hematologic disorders 0 1 2 3 4 5 Autologous BMT 0 1 2 3 4 5 2015 Medical Staffing Network Rev. 06/15 F01202 Oncology 4 of 7

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Care of the Patient - cont. Allogeneic BMT 0 1 2 3 4 5 BMT complications 0 1 2 3 4 5 Infection 0 1 2 3 4 5 Graft rejection 0 1 2 3 4 5 GVHD Graft-Versus-Host Disease 0 1 2 3 4 5 Care of Oncology Adverse Effects Compromise: Other Nausea/vomiting/diarrhea 0 1 2 3 4 5 Stomatitis 0 1 2 3 4 5 Neuropathy 0 1 2 3 4 5 Neutropenia 0 1 2 3 4 5 Thrombocytopenia 0 1 2 3 4 5 Nutritional needs 0 1 2 3 4 5 Fever 0 1 2 3 4 5 Infection 0 1 2 3 4 5 Septic shock 0 1 2 3 4 5 Cardiovascular Compromise Cardiac dysrhythmias 0 1 2 3 4 5 Superior vena cava syndrome 0 1 2 3 4 5 Cardiac tamponade 0 1 2 3 4 5 Carotid rupture 0 1 2 3 4 5 Lymphedema 0 1 2 3 4 5 Respiratory Compromise Pneumonia 0 1 2 3 4 5 Atelectasis 0 1 2 3 4 5 Pneumothorax 0 1 2 3 4 5 Pleural effusion 0 1 2 3 4 5 Pulmonary embolism 0 1 2 3 4 5 Respiratory distress 0 1 2 3 4 5 GI/GU Compromise Bowel obstruction 0 1 2 3 4 5 Renal failure 0 1 2 3 4 5 Pancreatitis 0 1 2 3 4 5 GI bleed 0 1 2 3 4 5 Hematologic Compromise DIC (Disseminated Intravascular Coagulopathy) 0 1 2 3 4 5 Hemorrhage 0 1 2 3 4 5 2015 Medical Staffing Network Rev. 06/15 F01202 Oncology 5 of 7

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Care of Oncology Adverse Effects Fluid & Electrolytes Compromise Electrolyte imbalances 0 1 2 3 4 5 Hypercalcemia 0 1 2 3 4 5 Hypovolemia 0 1 2 3 4 5 Skin & Muscle Stress fractures 0 1 2 3 4 5 Spinal Cord Compression (SCC) 0 1 2 3 4 5 Care of Patients Receiving Radiation therapy 0 1 2 3 4 5 External radiotherapy 0 1 2 3 4 5 Total body irradiation 0 1 2 3 4 5 Intraoperative Radiation Therapy (IORT) & implants 0 1 2 3 4 5 Brachytherapy 0 1 2 3 4 5 Radiation safety procedures 0 1 2 3 4 5 Age Specific Competencies Newborn/neonate (birth-30 days) 0 1 2 3 4 5 Infant (31 days-1 year) 0 1 2 3 4 5 Toddler (ages 2-3 years) 0 1 2 3 4 5 Preschool (ages 4-5 years) 0 1 2 3 4 5 School age (ages 6-12 years) 0 1 2 3 4 5 Adolescent (ages 13-21 years) 0 1 2 3 4 5 Young adult (ages 22-39 years) 0 1 2 3 4 5 Adult (ages 40-64 years) 0 1 2 3 4 5 Older adult (ages 65-79 years) 0 1 2 3 4 5 Elderly (ages 80+ years) 0 1 2 3 4 5 2015 Medical Staffing Network Rev. 06/15 F01202 Oncology 6 of 7

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Please list any Additional Skills: 1. 2. 3. 4. Additional training: 1. 2. 3. 4. Additional equipment: 1. 2. 3. 4. Fax to: 1-888-298-3146 The information on this and all preceding pages is true and correct. Signature Date 2015 Medical Staffing Network Rev. 06/15 F01202 Oncology 7 of 7

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