AGE SPECIFIC COMPETENCY ASSESSMENT

EMPLOYEE ___________________________________________
                                                                         POSITION ___________________________________________                                     

DEPARTMENT _________________________________________

This checklist must be completed by all employees who have regular clinical 
contact with patients, as defined by policy. Signature indicates the employee 
was observed to demonstrate the age specific competency. Signature may be 
provided by DON, Charge RN, House Supervisor, licensed preceptor, CNS.  

N/A=Not Applicable

DATE                                               MEDICAL RECORD    SIGNATURE 
                                                   NUMBER AND AGE

A.

Newborn/Infant (0-12 months)
Involves parents in healthcare decisions and 
teaching; incorporates age, weight and 
physiological needs into assessment; 
provides for physically and emotionally safe 
environment ; allows for free motor play.

Comments:




________________________________________________________________________________
B.

Toddler (13 mo-3 yrs)
Involves parents in healthcare decisions and 
teaching; identifies motor/social skills to 
involve patient as appropriate; uses age 
appropriate materials; allows choices when 
possible; incorporates cultural and religious 
beliefs communication by parents into care.

Comments:





________________________________________________________________________________
C.

Preschool (4-6 yrs)
Uses language child can understand; 
considers motor and social skills to involve 
child in care; uses games, rewards, praise; 
supports independence and sense of control; 
resolves fear of mutilation and pain; provides 
opportunity for self-expression.

Comments:




________________________________________________________________________________
D.

School Age (7-12 yrs)
Involves patient in choices as possible; 
provides for privacy; encourages verbalization 
of feelings; encourages socially acceptable 
behavior; encourages self care.

Comments:




________________________________________________________________________________
E.

Adolescence (13-17 yrs)
Uses understandable terminology and 
rationale; encourages questions; involves 
patient in decision making and planning; 
recognizes that resistance may occur; 
recognizes need for privacy.

Comments:





________________________________________________________________________________
F.

Adult ( 18-64 yrs)
Involves patient in decision making; provides 
education to patient and significant other(s); 
fosters increased self-esteem; allows to 
verbalize fears and concerns; incorporate 
social activities and financial needs into 
discharge plans.

Comments:


G

Geriatric (65+ yrs)
Assesses patient ability to care for self; 
speaks clearly, directly in controlled tone; 
allows time for processing new information; 
identifies strategies for coping with loss; 
encourages participation in plan of care; 
focuses on strengths and abilities; asks 
opinions; avoids making decisions for patient.

Comments:




________________________________________________________________________________
______This employee has been assessed to be competent.  
______This employee has not demonstrated competency in the required category 
      checked below.

_____Newborn/Infant _____Preschool  _____Adolescence  _____Geriatric

_____Toddler		  _____School Age	_____Adult


                                                                                                                   
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Evaluator Signature				        Date



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Title



_________________________________              _________________ 
Employee Signature               			  Date