PEDIATRIC AFTER HOURS CLINICS
LICENSED & NON-LICENSED STAFF
EMPLOYEE NAME:
2015-2016
Competency and Compliance Plan
When complete (with included dates), please submit to your unit’s designated repository.
Employees are also accountable for completing any additional Learning Exchange Modules
assigned throughout the year.
This must be completed and submitted no later than April 30, 2016
The information and competency data I submit are complete (with dates), true, and accurately reflects my work and abilities to function as a licensed staff member in my department. If I completed an “Observation of Daily Work” or “Case
Study,” I submitted these items through the designated online submission site. I understand that my ongoing professional
growth is my responsibility and that I will notify my educator or designated department leader if I have further training
Employee’s Signature
Date
CSL/Manager’s Signature
Date
Competency Transition Year: January 1, 2015-April 30, 2016
UNIT COMPETENCIES
Page 2
Validation Criteria/
Methods of Verification
Competency
Completion
(Dates must be included)
FOR LICENSED STAFF
JC HR.01.05.03 EP 3 & VUMC CL 30-08.21 & CL 30-19.22
Clinical Emergency
Response
(RR/Mock Code)
Demonstrates and communicates role in
activating or participating in the Tiered
Response Team, STAT Team, and/or Code.

2015-2016 CAVE Event
OR

Hands On Clinical Safety Event
OR

Date________________
Observation of Daily Work
(Online Submission)

OR
The following training in Jan 2015-June 2016:
PEARS or PALS
VUMC CL 30-06.30 & OP 30-10.04; HR-035
Medication Diversion
Demonstrate knowledge of Safe Medication
Administration and how to act in a situation
where Medication Diversion is suspected.
3 Learning Exchange Modules:

“Medication Diversion Accountability—Licensed
Staff 2015”

“The Impaired Caregiver—Licensed Staff 2015”

“Safe Medication Administration Practice 2015”

Learning Exchange Module:
Date_________
Date_________
Date_________
VUMC CL 20-07.03 & CL 30-19.02
Basic Arrhythmia
“2015-2016 VCH Pediatric Basic Arrhythmia”
Demonstrates ability to recognize, intervene, and elevate acute events involving
the heart and vascular systems.
Date_________
FOR NON-LICENSED SATFF
JC HR.01.05.03 EP 3 & VUMC CL 30-08.21 & CL 30-19.22
Clinical Emergency
Response
(RR/Mock Code)

Demonstrates and communicates role in
activating or participating in the Tiered
Response Team, STAT Team, and/or Code.

2015-2016 CAVE Event
Date________________
OR
Observation of Daily Work
VUMC CL 30-06.30 & OP 30-10.04; HR-035
Medication Diversion
Demonstrate knowledge of Safe Medication
Administration and how to act in a situation
where Medication Diversion is suspected.
2 Learning Exchange Modules:
“Medication Diversion Accountability—Non
Licensed Staff 2015”
Date_________
“The Impaired Caregiver—Non Licensed Staff
2015”
Date_________
Trouble finding the online submission site for “Observation of Daily Work” and “Case Study”?
Visit Vanderbilt’s Nursing site and type in “Competency.” Children’s competency site can be found under “Ongoing Competencies and
Skills.”
UNIT COMPETENCIES
Page 3
Validation Criteria/
Methods of Verification
Competency
Completion
(Dates must be included)
Mosby's Skills: Patient and Family Education
Patient and Family Asthma 
Education in the Outpatient
Setting
Demonstrates ability to correctly educate
families on Asthma and medication dosages
for fever and pain reducers.

Observation of Daily Work (online submission)
Date_________
OR
Mock Event (arranged with unit educator)
If Mock Event
Name of Trainer:_____________________
Signature: __________________________
Role: ______________________________
VUMC CL 20-07.03 & CL 30-19.02
AH Emergency Response in 
the Outpatient Setting
Demonstrates ability to respond
appropriately to an emergency situation in
an outpatient setting.
Respiratory Assessment
Demonstrates ability to accurately assess
respiratory distress and intervene appropriately within the scope of practice.
LMS Module
Date______________
"2015 CHOC Emergency Response in the
Outpatient Setting"
If Mock Event
(Online Submission)
OR
Signature: __________________________

Mock Event

Observation of Daily Work (online submission)
(arranged with unit educator)
OR

Name of Trainer:_____________________
Mock Event (arranged with unit educator)
Role: ______________________________
Date_______________
If Mock Event
Name of Trainer:_____________________
Signature: __________________________
Role: ______________________________
Medication Administration
in the Outpatient Setting
Demonstrate ability to appropriately
calculate and infuse antibiotics via the
intramuscular, intravenous and oral routes
within the scope of practice.

Observation of Daily Work (online submission
OR

Mock Event (arranged with unit educator)
Date________________
If Mock Event
Name of Trainer:_____________________
Signature: __________________________
Role: ______________________________
Trouble finding the online submission site for “Observation of Daily Work” and “Case Study”?
Visit Vanderbilt’s Nursing site and type in “Competency.” Children’s competency site can be found under “Ongoing Competencies and Skills.”
Page 4
Compliance Requirements
Note: Compliance items require completion on an annual basis and may need to be completed
twice during this competency transition year (1/1/15-4/30/16) to remain compliant.

TB Skin Test

Point of Care Training
Consult your CSL or unit educator for POCT requirements
________________
(Staff can only re-cert within
3 months of expiration.)
POCT 1 ______________________________
POCT 2 ______________________________
POCT 3 ______________________________
POCT 4 ______________________________
POCT 5 ______________________________
POCT 6 ______________________________

N95 Fit Testing

Human Resources Annual Modules
 2015 Standards of Conduct and Confidentiality Training
 2015 Privacy and Information Security (HIPAA)
 2015 Annual Policy Review
________________
________________
________________
________________
VandySafe Modules:
As VandySafe Modules do not get released to staff until the fall, a separate document will be published at that time outlining
the unit specific requirements for completion.