HHA Skills Evaluation Checklist Revised 5-17-16 - New York State ...

HOME HEALTH AIDE (HHA)

UNIT XII SKILLS EVALUATION CHECKLIST

BPSS ¨C REGULATED SCHOOLS

HHA Student Name:

School Name:

Instructor:

HHA Training Dates: (Start Date): _____/_____/_____

BPSS Instructor License #:

- (End Date): _____/_____/_____

Dates of 8 Hour Internship: (Start Date): _____/_____/_____

- (End Date): _____/_____/____

Internship Site:_______________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Internship Address:______________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

(Start Date):__________ (End Date):__________ (Start Time):__________ (End Time):__________

During Unit XII a student must successfully demonstrate the skills listed. The checklist is from the Department of Health (DOH) Appendix

in the Homecare Curriculum and the Health-Related Tasks Curriculum. There are 12 required skills, which are bolded with an *. Any 2

additional skills must also be successfully demonstrated during the supervised skills training in the lab/skills class. This first set of

required skills addresses the Personal Care Aide (PCA) portion of the HHA training. The HHA Health-Related Tasks require the

successful demonstration of an additional 18 mandated skills, which are numbered and begin on page 3. These tasks may be demonstrated

in either the lab/skills class or during the internship and must be evaluated according to the DOH guidelines. The school should document

compliance on this required checklist and the completed sheet kept in the student¡¯s file, with a copy given to the student upon completion.

Indicate

Date Student

Date Skill was

where student

Initials of

successfully

demonstrated

demonstrated

Teacher at

Clinical Skills

demonstrated

Comments

by the

skill: at School

School (S) or

skill by him

instructor

(S) or

Internship (I)

or herself

Internship (I)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

Proper Handwashing*

Proper Body Mechanics

Tub or Shower Bath

Turning the Client in Bed

Bed Bath*

Shampoo in Bed

Back Rub

Nail Care

Shaving the Client

Mouth Hygiene and Care*

Assisting with Eating

Assisting with Dressing

Assisting with using the Elastic

Support Stockings

Helping Client to Walk*

Making an Unoccupied Bed

Making an Occupied Bed*

Use of a Bedpan*

Use of Urinal

Assisting w/ Use of Condom

Catheter

Assisting with Cleaning the Skin &

Catheter Tubing

Assisting w/ emptying Urine

Drainage Bag

Page 1 of 4

HOME HEALTH AIDE (HHA) TRAINING PROGRAM

BPSS ¨C REGULATED SCHOOLS

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

Positioning of Client in Bed

Transfer Client to Sitting Position

Helping Client to sit on Bed

Helping a Client to Stand

Transfer to Wheelchair, Chair or

Commode*

Positioning Client in Wheelchair or

Chair

Transfer from Wheelchair to toilet

Transfer from Wheelchair to Shower

& Assist w/ Shower

Transfer from Wheelchair to Stool

or Chair in Tub

Weighing a Client

Measuring Intake

Measuring Urinary Output

Assisting w/ Changing Clean

Dressing

Handling the Infant

Infant Bath

Assist w/ use of Hydraulic Lift

Slide Board Transfer

Checking the Right Person*

Checking the Right Medication*

Checking the Right Dose*

Checking the Right Time*

Checking the Right Route*

Knowledge Evaluations

(Tests must be kept in the student folder)

Unit I

Unit II

Unit III

Unit IV

Unit V

Unit VI

Unit VII

Unit VIII

Unit IX

Unit X

Unit XI

Unit XII

Date of Test

Instructor

Initials

Pass (P) or

Fail (F)?

If first

Failed,

Date of

Pass

Instructor

Initials

Introduction to Home Care

Working Effectively w/

Homecare Clients

Working w/ the Elderly

Working w/ Children

Working w/ People who are

Mentally Ill

Working w/ People w/

Developmental Disabilities

Working w/ People w/

Physical Disabilities

Food, Nutrition & Meal

Preparation

Family Spending &

Budgeting

Care of the Home & Personal

Belongings

Safety & Injury Prevention

Personal Care Skills

Page 2 of 4

Clinical Skills

1) A-1

2) B-1

3) B-2

4) B-8

5) B-9

6) D-1

7) D-2

8) D-3

9) D-4

10) D-5

11) E-9

12) E-10

13) E-11

14) F-1

15) F-2

16) G-1

17) H-1

18) H-5

HOME HEALTH AIDE (HHA) TRAINING PROGRAM

BPSS ¨C REGULATED SCHOOLS

Date Student

Date Skill was

Initials of

Successfully

Demonstrated

Instructor

Demonstrated

by the

Demonstrating

Skill - by him

Instructor

Skill

or herself

Positioning on the side*

Assisting w/ changing a clean

dressing*

Assisting w/ changing an

ileostomy or colostomy

pouch*

Assisting w/ routine

tracheotomy care*

Unit F

Orientation to Health Oriented

Tasks

Performing Simple

Measurements & Tests

Complex Modified Diets

Assisting w/ Prescribed

Exercise Program

Assisting w/ use of Prescribed

Medical Equipment, Supplies &

Devices

Assis w/ Special Skin Care

Unit G

Assist w/ a Dressing Change

Unit H

Assisting w/ Ostomy Care

Unit B

Unit C

Unit D

Unit E

Comments/

Demonstrated

in Lab or

Internship?

Proper Hand Washing*

Cleaning a glass thermometer*

Measuring an oral temperature

w/ glass thermometer*

Measuring the pulse and

respirations*

Measuring blood pressure*

Transfer to a sitting position*

Helping client to sit at side of

bed*

Helping a client to stand*

Assisting with passive range of

motion exercises *

Assisting w/ postural drainage*

Assisting w/ use of oxygen

concentrator*

Assisting w/ use of oxygen

reservoir*

Assisting w/ use of medication,

nebulizer and air compressor*

Positioning on the back*

Knowledge Evaluations

(Tests must be kept in the student folder)

Unit A

Initials of

Instructor

Signing off

on Skill

Date of Test

Instructor

Initials

Pass (P) or Fail

(F)?

If first

Failed, Date

of Pass

Instructor

Initials

Page 3 of 4

HOME HEALTH AIDE (HHA) TRAINING PROGRAM

BPSS ¨C REGULATED SCHOOLS

NOTES & COMMENTS:

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

We hereby certify that the clinical skills performance record evaluation depicted above is true and correct and that the named

Home Health Aide has successfully demonstrated all indicated skills; has done the required 8 hours of internship at the place and

date(s) listed above and only upon completion of the internship has been entered as ¡°certified¡± on the Registry. A copy of this

completed evaluation checklist has been given to the Home Health Aide (HHA).

HOME HEALTH AIDE (HHA) TRAINING PROGRAM

DIRECTOR OR INSTRUCTOR

SIGNATURE: ____________________________________

DATE: __________________________

HOME HEALTH AIDE (HHA) INSTRUCTOR

SIGNATURE: ____________________________________

DATE: __________________________

HOME HEALTH AIDE (HHA) TRAINEE

SIGNATURE: ____________________________________

DATE: __________________________

BPSS ¨C MAY 2016

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