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RN - Clinical Documentation and Improvement

This checklist was electronically signed on September 12, 2026

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

PATIENT RIGHTS

Communicate and obtain information while respecting patient rights, privacy, and confidentiality of information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Involve the patient and family and respect their role in determining the nature of care to be provided
Meet patient's and families' needs regarding communication, including interpreter services
Provide accurate information to patients and families in a timely manner

COMMUNICATION

Communicate with patients and their companions in a courteous manner
Understand the chain of communication, who to contact, and when
Listen actively to patient concerns and address them appropriately.
Cultural Sensitivity and Language Skills

GENERAL INFECTION CONTROL MEASURES

Aseptic Technique
Standard Precaution
Universal Precaution

TRANSMISSION-BASED PROTOCOL

Airborne Precaution
Contact Precaution
Droplet Precaution
Reverse Precaution

REGULATORY AGENCIES

American Nurses Association (ANA)
Agency for Healthcare Research and Quality (AHRQ)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare & Medicaid Services (CMS)
Nurse Practice Act
Occupational Safety and Health Administration (OSHA)
State Departments of Health
State Boards of Nursing
The Joint Commission

CLINICAL

Clinical Guidelines
Disease Process
Medical Terminologies

DOCUMENTS

Annual PT
ANSPAR
ARST
Behavioral Crisis Intervention Plan (BCIP)
BSCPAP
Budget Worksheets with units matching requested on the TSPAR
CPT
CARMP
Case Management
Customized In-Home Supports
CCS Individual
CCS Group
CIE Intensive
CIE Group
CIE Self-Employment (Standard/Intensive)
CIE Job Maintenance Monthly
Denial Management
DRG
DDW Crisis Supports prior Authorization Memo
ECHAT
Family Living
Fiscal Management for Adult Education Opportunity
Independent Living Transition Services
ISP
IDT Minutes from Crisis
Initial or Ongoing PRSC Service Delivery
Independent Living Transition Services
Initial or Annual Positive behavior
ICD - 9
ICD -10
Job Aide/Community Inclusion Aide
Leads CDI-applicable presentations to Ancillary departments (Physical Therapy, Nursing, Dietary, etc.)
MAC
MCC
MAAT
Non-Medical Transportation
OASIS-C
Positive Behavior Support Assessment (PBSA)
Positive Behavior Support Plan (PBSP)
Psychotropic Medication Plan
QIO
RAC
Respite
Review medical records for conflicting, incomplete, or non-specific documentation by the provider
Risk Management Plan (RMP)
Staffing Grid
Supported Living
Transportation Mile
TSPAR
Verification of Benefits Availability Form
Vision/Outcomes

DATA MANAGEMENT

Create reports, display data, and provide narrative analysis to a variety of audiences
Effectively and efficiently create clinical case summaries from a variety of medical record documentation for internal and external audiences
Microsoft Excel
Microsoft PowerPoint
Microsoft Word
Other software tools for the analysis and presentation of related data
Substantiate activity by documentation that is entered per Health and Department of Coordinated Care Guidelines

COMMUNICATION AND INTERPERSONAL SKILLS

Clearly and concisely communicate with the staff, patients, families, and other medical professionals.
Demonstrate excellent written and oral skills

CRITICAL THINKING

Analyze Medical Records
Evaluate Clinical Evidence to Support Diagnoses and Procedures
Identify Gaps, Discrepancies, and Inconsistencies
Keen Attention to Details

MEDICATIONS

Antianginal
Antiarrhythmic Drugs
Anticholinergic
Anticoagulants/Thrombolytics
Antidiabetic Drugs
Antihyperlipidemic Drugs
Antihypertensive
Anti-Infectives
Anti-Inflammatory/Analgesic Drugs
Diuretics
Electrolyte Therapy
Gastrointestinal Drugs
Hormones
Mental Health Medications
Muscle Relaxants
Narcotics/Opioids
Neurocognitive Drugs
Neuromuscular Blocking Agent
NS Stimulants
Ophthalmic
Pulmonary Drugs
Steroids
Vaccines

AUTOMATED MEDICATION DISPENSING SYSTEMS

Accudose
Metro
Omnicell
Promanager Rx
Pyxis
eMAR

ELECTRONIC DOCUMENTATION

Allscripts
Care360
Cerner (Oracle)
CPSI
eCLinicalWorks
Eclipsys
EPIC
MACLAB
McKesson/Paragon
Meditech
PACS
Quadramed
Soarian

AGE-SPECIFIC COMPETENCIES

Newborn/Neonate (birth-30 days)
Infant (30 days-1 year)
Toddler (1-3 years)
Preschooler (3-5 years)
School-age children (5-12 years)
Adolescents (12-18 years)
Young adults (18- 39 years)
Middle adults (39- 64 years)
Older adults (64-79 years)
Elderly adults (80+ years)