Supervised skill validation

Use with a qualified assessor and the device-specific facility checklist. This supporting worksheet does not authorize a procedure or replace an approved competency policy.

Learner: Role:

Skill/device: Date:

Assessor/credentials:

Facility policy/version and product instructions:

Observe and document

• Confirms the order, indication, patient identification, consent and scope limits.
• Assesses therapy compatibility, patient risks, vessels and DIVA risk; explains device choice and escalation.
• Performs hand hygiene, protects key parts/sites and uses appropriate barriers.
• Checks allergies, follows approved antiseptic application instructions and allows complete natural drying.
• Uses equipment and visualization within validated scope; follows attempt limits and escalates safely.
• Confirms device function and required tip location before use; never forces a resistant flush.
• Applies appropriate securement/dressing and device-specific maintenance.
• Recognizes complications/stop points and describes the correct escalation and agent/device-specific response.
• Documents attempts, findings, device details, verification, education, actions and handoff.

Assessor outcome

☐ Validated for the observed skill under policy
☐ Further practice / reassessment required

Strengths, gaps and remediation plan (no patient identifiers):

Assessor signature/date:

Learner acknowledgment: