UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF ALLIED HEALTH PROFESSIONS
DEPARTMENT OF CARDIORESPIRATORY CARE
Clinical Competency Checklist
Low Flow Oxygen Therapy Initial Setup (cannula, mask, rebreather)
Student Name _______________________________ Date _________________ Attempt # _______
Rating Scale:
0 = inappropriate, incorrect, or omitted
1 = needs additional study and practice
2 = completed appropriately and correct
N/A = not applicable
ITEM
RATING
1. Gathers necessary equipment for O2 setup
______
2. Verifies written physician order to assure oxygen delivery device and flow.
______
3. Washes hands
______
4. Assures patient identity
______
5. Installs flowmeter in appropriate outlet
______
6. Assembles humidifier aseptically (if indicated)
______
7. Attaches humidifier properly to flowmeter (if indicated)
______
8. Attaches delivery device snugly to humidifier or flowmeter
______
9. Sets ordered flow
______
10. Tests pressure pop-off valve (if present)
______
11. Attaches device properly to patient, allows time to reach baseline, then checks SpO2
______
12. Posts no smoking sign (if indicated by NFPA 99, Section 8-6.4.2)
______
13. Records data in chart and/or other facility records (e.g. computer) to include:
SpO2, date, time, device and flow.
100% proficiency required to pass
______
Total = _____ out of 26
Score = _____ pass _____ fail
Instructor’s Signature: _________________________________________
Instructor's Name: ______________________________ Credential: ______
(Please print)
Student's Signature: ____________________________________________
Comments __________________________________________________________________________