Kingdom of Saudi Arabia

Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

Nursing Education & Staff Development

Nursing Competency Program

Blood Glucose Estimation

Employee Name: __________________________ ID No. : ___________________________

Department/Unit: __________________________ Date of Joining: ____________________
Competency Start Date: _____________________

Competency Assessment Instructions – This Template must NOT be altered:

1. All ELEMENTS of the Competency (KSA) must be assessed by the patient bedside.
2. The Assessor is obliged to √ each element assessed in the first column.
3. The Remarks column should only be used to comment when the employee is unable to complete the element being
assessed. The Assessor is required to write a comment e.g. “More preparation needed and will be reassessed on the
date and time”.
Competency Statement :
Ability to Operate blood sugar testing equipment in area of practice. Indicate N/A for any competency
elements that are not relevant to area of practice.

CRN
Knowledge (√each element) Title Date Remarks
Signature
1 State accurately & explain definition of
---------- blood glucose estimation.
2 State accurately the purpose of monitoring
---------- blood glucose levels.
3 State and explain the process of monitoring
---------- blood glucose levels.
CRN
Skills (√ each element) Title Date Remarks
Signature
1 Demonstrate the process of monitoring blood
---------- glucose levels.
2 Identify the equipments needed for the
---------- procedure.
3 Complete & discuss the role of the nurse in
---------- monitoring blood glucose levels.
4 Carry out the nurse’s role and responsibility
---------- when monitoring blood glucose levels
including the immediate action to be taken,
completion of the necessary reporting
procedure and documentation required
CRN
Attitude (√each element) Title Date Remarks
Signature
1 Ability of nurse to respond professionally and
---------- calmly if patient refuse monitoring blood
glucose levels.
2 Truthfullness of the nurse to report and
---------- documenting the abnormal readings
3 To be self-aware of limitations in knowledge
---------- and skills and verbalize these with nurse in
charge

Approved for Use in 26-June-18 NS Page 1

 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

Nursing Education & Staff Development

Nursing Competency Program

Blood Glucose Estimation
4 To be approachable and open to answer
---------- patient and family's questions.
5 Attentive to overall patient experience e.g.
---------- pain, anxiety and have ability to provide
comfort and emotional support as needed
Reference, Websites and Training Requirements:
(These must be completed at least 1 month prior to the Competency Assessment. Policies must be numbered
with the Policy Title; Books referenced must state the specific Chapter for employee to read.)
Reference, Websites and Training
www.RnCeus.com
www.heart.org
http:circ.ahajournals.org
www.ihi.org/IHI/Programs/Campaign.
www.ihi.org/IHI/programs/campaign/campaign.htm
http://www.icsi.org/.
http://www.rcplondon.ac.uk/resources/national-early-warning-score-news.
www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf.
EBSCOhost: Early warning scores: effective use.
http://pediatrics.aapublications.org/content/125/4/e763.full.html
Review of Medical Records Policy on Patient Administration (Blood Glucose Estimation GNR-010) NSPP
Approved Abbreviation List
Attended In-Service Refresher

Specific Learning Performance Learning Strategies Comments for Follow-up

Opportunity Identified Expectations with Agreed with Deadline Learning Strategies and
Deadline Deadline Date/s
1. 
1.
2.
3.
4.
5.

Competency Completed by: ___________________________________

Designation: _______________________________________________
Date:_____________________
NAME OF EMPLOYEE ID # SIGNATURE DATE COMPETENCY
ASSESSMENT COMPLETED

When completed, the Original must be given to the CRN who will collate the Compliance Rates for the Unit and
before sending it on to the Education Department. The Education Department will collate the Compliance Rates
for the Nursing Services Department. The Original is to be given to the Employee for their Portfolio and a hard
copy kept in the Employee’s Unit and Nursing Department file.

Original – Employee for Portfolio

Copy held by Head Nurse/CRN in Unit
Copy held in Nursing/Education Department

Approved for Use in 26-June-18 NS Page 2