CYNET_SYSTEMS_MAIN_LOGO.gif   Phlebotomy Competency Skills Checklist
   NAME    
   LAST 4 OF SSN      
   DATE      
I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) Preparation 1 2 3 4  
Introduces self to patient and explains blood tests have been ordered by physician.  
Identifies the patient with two unique identifiers (armband, ask for name & DOB).Compare patient ID information with barcode label.  
Checks testing requirements (ie fasting).  
Prepares supplies and tube selection.  
Washes hand, dons gloves.  
Rating Stars (Click) Getting Started 1 2 3 4  
Positions Patient and applies tourniquet.   
Palpates antecubital area to select venipuncture site.   
Properly cleanses venipuncture site.  
Rating Stars (Click) Sample Collection 1 2 3 4  
Stablizes vein.  
Inserts needle, bevel up.  
Smoothly pushes tube(s) into holder without changing needle position.  
Adjusts needle, if necessary, to obtain flow then stablizes vacutainer.  
Releases tourniquet as blood begins to flow.  
Changes vacutubes without changing needle position.  
Fills vacutubes in correct order.  
Mixes anticoagulated vacutubes properly.  
Removes last tube from needle before withdrawing needle.   
Withdraws needle from arm smoothly.   
Applies pressure to site after withdrawing needle.   
Disposes of needle properly and safely, Discards tourniquet.  
Rating Stars (Click)  Handling & Processing 1 2 3 4  
Labels tubes immediately (ie at bedside).  
Legibly completes label/requisition with username and date/time of collection.  
Observe special handling requirements.  
Checks puncture site to ascertain bleeding has stopped. Applies bandage.  
Places tubes into biohazard bag. Label(s)/requisiton are placed in sleeve of bag.  
Removes gloves and practice hand hygiene.  
Transport specimens to lab via porter or pneumatic tube system. STATs are sent immediately.  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click)  Age Specific Competencies 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)