UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF ALLIED HEALTH PROFESSIONS
DEPARTMENT OF CARDIORESPIRATORY CARE
Clinical Competency Checklist
High Flow Oxygen Therapy Initial Setup (Venturi Mask)
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. Checks written physician order (FiO2).
______
3. Washes hands
______
4. Assures patient identity.
______
5. Installs flowmeter in oxygen outlet
______
6. Places nipple adapter on flowmeter (if applicable)
______
7. Sets FiO2 on mask
______
8. Places oxygen tubing between mask and nipple
______
9. Sets flow setting appropriately for FiO2 and patient size
______
10. Places mask on patient, allows time to reach baseline, then checks SpO2
______
11. Posts no smoking sign (if indicated by NFPA 99, Section 8-6.4.2)
______
12. Records data in chart or other facility records (e.g. computer) to include SpO2,
date, time, device, and FIO2.
______
13. Completes other departmental record keeping.
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 ________________________________________________________