Human Resources Code: HR-FO-08

Edition: 3
Competency Testing Checklist

Employee Name:
Position:
Department/Division/ All Nursing Units
Unit:
Date: Valid for: 1 year  2 years 
Competency Tested: Oxygenotherapy

Element Competent Remarks

Yes No
1. Perform hand hygiene and standard universal precaution
2. Know the indication and possible complication of
procedure (hyper or hypo oxygenation)
3. Installation and Maintenance of the Oxygen
Bubbler(Principles, Procedure for replacing bubbler water,
Cleaning)
4. Know the indications for oxygenotherapy (hypoxia,
asthma, pulmonary embolism, acute lung edema, anemia,
etc).
5. Prepare the necessary equipments (Oxygen sensor,
Sterile water for humidifier, Oxygen source (wall or shell).
6. Select the necessary oxygenation equipment (nasal tube,
face masque, venture face masque, etc..)
7. Connect the probe to the pipe which is connected to the
flow meter and apply the treatment process (semi-sitting
position, observation, etc.)
Total Note
Total %

Method of Evaluation: O= Observation , RD= Return Demonstration , T= Written Test , V= Verbal Review


Recommendations/ Follow up Actions:

Co ( Competent: ≥ 85% of total № of elements Incompetent: <85% of total № of elements

Name and Signature of Evaluator: ………………………………………………..........................

* Yes = 1 No = 0.
* It is allowed to add the number of rows needed for additional elements.

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