UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF ALLIED HEALTH PROFESSIONS
DEPARTMENT OF CARDIORESPIRATORY CARE
Clinical Competency Checklist
Incentive Spirometry
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 (spirometer).
______
2. Checks written order for incentive spirometer
______
3. Washes hands
______
4. Assures patient identity
______
5. Completes patient assessment
______
6. Assembles spirometer
______
7. Explains the rationale for the therapy
______
8. Instructs the patient how to perform the therapy
______
9. Has patient perform the therapy 6-10 times.
______
10. Performs necessary charting to include inspired volume,
quality of patient effort, quality of cough, and breath sounds
______
11. Completes other documentation.
______
100% proficiency required to pass
Total = ________ out of 12
Score = _____ pass _____ fail
Instructor’s Signature: _________________________________________
Instructor's Name: ______________________________ Credential: ______
(Please print)
Student's Signature: ____________________________________________
Comments ________________________________________________________