NG Tube Competency Form
Assessment and documentation of competency in nasogastric (NG) tube care and related procedures.
Full Name of Assessed Individual
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Trainer/Evaluator Name
*
Role/Position
*
Please Select
Nurse
Nursing Assistant
Student
Other
Knowledge of Indications and Contraindications for NG Tube Insertion
*
Demonstrates full understanding
Partial understanding
Requires further education
Practical Skill Checklist: Please check all steps correctly demonstrated
*
Gathers and prepares equipment
Performs hand hygiene
Explains procedure to patient
Measures and marks tube
Lubricates tube
Inserts tube correctly
Verifies placement
Secures tube and documents
Rate the Assessed Individual’s Overall NG Tube Insertion Technique
*
1
2
3
4
5
Input Table: Knowledge of Key NG Tube Care Concepts
*
Rows
Understands
Needs Improvement
Not Assessed
Tube placement verification
1
2
3
Feeding and medication administration
4
5
6
Tube care and maintenance
7
8
9
Complication recognition
10
11
12
Outcome of Competency Assessment
*
Competent
Requires further training
Additional Comments/Recommendations
Submit Competency Form
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