Orientation Competency Assessment of CPE Student
CPE Student Name:
CPE Unit & Start Date: ______________________________________________
Competency Assessor Name:_________________________________________
Assessment Verification, Start Date:
___
Finish Date:
_______
Method of Verification
O = Observation
D = Demonstration
T = Test
D/I = Discussion/Interview
Please note that this competency verification form must be completed and signed prior to clinical assignment and filed in CPE
Student folder.
Institution
Competencies
Method of
Verification
Infection Control
☐O ☐D
☐T ☐D/I
Confidentiality
☐O ☐D
☐T ☐D/I
Fire Safety
☐O
☐T
☐O
☐T
☐O
☐T
☐O
☐T
Conflict of Interest/
Compliance
☐O ☐D
☐T ☐D/I
Department
Competencies
Care Plan,
Assessment &
Intervention
Technology Usage
Documentation
Bereavement
Program
Method of
Verification
Advance Directives
Code Blue
2 Stop
Spiritual Care
Response Team
Functions
Virtual Pastoral Care
e.g. e-Chaplaincy
Interdisciplinary
Function
Demonstrate PPE to
another co-worker
Met/
Not Met
Action Plan If
Applicable – Yes/No
Evaluator
Signature
Date
Date Verification
Completed
Met/ Not
Met
Action Plan If
Applicable – Yes/No
Evaluator
Signature
Date
☐D
☐D/I
☐D
☐D/I
☐D
☐D/I
☐D
☐D/I
☐O ☐D
☐T ☐D/I
☐O
☐T
☐O
☐T
☐O
☐T
☐O
☐T
☐O
☐T
☐O
☐T
☐O
☐T
Date Verification
Completed
☐D
☐D/I
☐D
☐D/I
☐D
☐D/I
☐D
☐D/I
☐D
☐D/I
☐D
☐D/I
☐D
☐D/I
Initial Core Pastoral Care Competencies
Ability to establish a therapeutic relationship with care recipients and exhibit trust.
Good interviewing and communication
skills with care-recipients.
Shows use of dynamic listening skills, and
an openness for new learning.
Uses appropriate empathy and
compassion.
Practices appropriate counseling and
dispute-mediation skills.
Demonstrates spiritual/religious
sensitivity.
Shows ability to harness the healing
resources of faith, hope and community.
Ability to recognize healing aspects of
other faith/spiritual/religious traditions.
Has the ability to perform on-call duties
and complete handoff procedure.
Ability to convey a professional, trained,
and educated image to other professionals
and administration.
Ability to function effectively in crisis
situations.
Practices effective collaboration in
department & among other disciplines.
Ability to use Epic to access census lists
and maneuver to do a unit search.
Ability to use Epic to find a patient using
the MRN number and initiate co-signing.
Ability to document a visit and complete
its various categories available in Epic.
Ability or understanding (if access is not in
place) to document Spiritual Assessment.
Demonstrates the ability to understand
and document statistics and metrics.
Add Column 3 ratings, divide by 17 and
insert Total.
Method of
Verification
Rate Competency #
- 1 thru 5 +
Action Plan to Improve if
number is below 3
Date
Completed
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
☐O ☐D
☐T ☐D/I
Total =
Has student completed hospital/institutional orientation?
☐ Yes ☐ No
Has student completed Pastoral Services Dept. orientation?
☐ Yes ☐ No
Is student up to date with MyEducation requirements?
☐ Yes ☐ No
Student demonstrated reasonable initial core competencies?
☐ Yes ☐ No
Preceptor/Manager Signature
Date
Certified Educator Signature
Date
Method of Verification
O = Observation
D = Demonstration
T = Test
D/I = Discussion/Interview
_______