This competency assessment form was completed by the IV Team nurse at the conclusion of the Hands-On Training. Staff nurses provided a copy of the assessment to their supervisors.

1. FSH COMPETENCY VALIDATION: STARTING PERIPHERAL IVS (ADULT)
Name: ____________________________ Unit: ______________
Preceptor: _________________________ Date: ______________
Has observed 3 IV starts by a VAT nurse and completed Observation Log.
Has completed pre hands-on-training learning packet.
Has passed pre learning quiz.
Before Procedure YES NO
1. Verifies order for peripheral IV.
2. Checks for allergies.
Setup for Procedure YES NO
1. Gathers appropriate equipment.
2. Washes hands.
3. Correctly identifies patient.
4. Introduces self and explains procedure to patient.
5. Assesses patient and selects appropriate vascular access device.
6. Prepares all equipment before venipuncture.
Procedure YES NO
1. Applies tourniquet properly.
2. Selects site for venipuncture with regard to procedure/treatment
constraints, patient preference, previous venipunctures, history or
mastectomy/lymphadenopathy (when applicable).
3. Correctly identifies need and properly applies warm packs.
4. Cleanses area according to policy without subsequent contamination.
5. Successfully performs venipuncture using angiocath.
6. Connects tubing and cap. Verifies placement by aspirating blood and
flushing. Maintains positive pressure flush by clamping tubing while
flushing or withdrawing syringe while injecting.
Post Procedure YES NO
1. Dresses, tapes, and labels IV according to policy.
2. Documents according to policy.
Number of IVs started during Hands-on Training session: ______

2. FSH COMPETENCY VALIDATION: STARTING PERIPHERAL IVS (ADULT)
Criteria for competency was MET NOT MET.
Action Plan: _________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature Date