Blood Draw Skills Assessment
Evaluate and document competency in blood draw procedures.
Participant Name
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Role of Participant
*
Please Select
Nurse
Phlebotomist
Medical Assistant
Student
Other
Skill Assessment Checklist
*
Rows
Performed Correctly
Needs Improvement
Not Performed
Hand hygiene performed
1
2
3
Correct equipment gathered
4
5
6
Patient identification confirmed
7
8
9
Site selection and preparation
10
11
12
Proper venipuncture technique
13
14
15
Sample labeling
16
17
18
Post-procedure care
19
20
21
Were universal precautions (e.g., gloves, sharps disposal) followed?
*
Yes
No
Complications observed during or after procedure
None
Hematoma
Fainting
Bleeding
Other
Assessor Name
*
First Name
Last Name
Assessor Comments and Recommendations
Submit Assessment
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