Attempt # ___
Initial Test

Retest

MLAB 2360: Clinical I
The Complete Urinalysis
Competency Assessment Form Time Limit = 40 minutes
Start Time: _______End Time:______ Student: ______________________________ Date: _______________
Patient Name: _______________________________________ Patient Identification Number ___________
Required for ALL testing
Performed Not Performed (Any

in a gray box indicates unsatisfied critical criteria)
 
Verifies the patient order against the patient name and identification number
 
Dons the appropriate PPE for the task
 
Appropriately discards waste
#

’s Required: 3 #

’s Received:___ PASS FAIL
Manual Dipstrip
 
Properly submerges the test strip in the specimen
 
Handles reagent strips appropriately (caps the bottle immediately)
 
Removes excess urine appropriately
 
Reads each test at the time interval determined by the manufacturer
 
Records graded reaction within ±1 unit of the automated result
#
 ’s Required: 4_ #  ’s Received:___ PASS FAIL
Automated Dipstrip
PASS FAIL
 
Properly submerges the test strip in the specimen



Handles reagent strips appropriately

Removes excess urine appropriately
 
Accurately records results
#
 ’s Required: 3 #  ’s Received:___
Selection of Additional Testing
 
Documents the appropriate confirmatory tests indicated based on dipstick results
Microscopic Urine Sediment Analysis
 
Selects AND labels appropriate tube for centrifuge
 
Properly loads the centrifuge
 
Properly decants supernatant to obtain standardized amount of urine sediment
 
Properly loads Kova slide or glass slide
 
Recognizes and records semi-quantitative results within ±1 unit of the instructor’s result
 
Recognizes and records qualitative results accurately
#

’s Required: 5 #

’s Received:___ PASS FAIL
Revised 9/2014

Attempt # ___
Initial Test

Retest

COMMENTS:_______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
ACTION PLAN IF CRITICAL CRITERIA NOT MET:
__________________________________________________________________________________________
__________________________________________________________________________________________
Instructor’s Signature:________________________________________
Student’s Signature:__________________________________________
Revised 9/2014