PERFORMANCE EVALUATION:
Oxygen Supply System

Lab Date:   Clinical Date: Agency Date:
Student Name:
Instructor Name:
Number of Times Observed in Clinical:
Number of Times Practiced in Clinical:
PASSING CRITERIA: Obtain 90% or better on the procedure. Tasks indicated by * must receive at least 1 point, or the evaluation is terminated. Procedure must be performed within the designated time, or the performance receives a failing grade.
 
SCORING: 2 points -- Task performed satisfactorily without prompting.
1 point -- Task performed satisfactorily with self-initiated correction.
0 points -- Task performed incorrectly or with prompting required.
NA -- Task not applicable to the patient care situation.
 

Tasks:

Peer Lab Clinical
* 1.

Obtains an H and an E cylinder and appropriate regulators from the storage areas

  2.

Releases the safety chain

  3.

Maneuvers the cylinder onto the cart

* 4.

Secures the cylinder to the cart with the safety chain

* 5.

Tilts the cart upright

* 6.

Releases the third wheel

* 7.

Removes the cylinder valve cap and gives an audible warning of the impending noise

* 8.

Cracks the cylinder with safe hand and valve positions

* 9.

Selects the correct reducing valve for intended use

*

10.

Secures the reducing valve to the cylinder

* 11.

Checks for and corrects any leaks

* 12.

Calculates the amount of time before the cylinder must be changed at a liter flow designated by the instructor

* 13.

Pushes the cart correctly to the patient area and back to storage

* 14.

Returns all the equipment to storage and properly secures it

           
  Score: Peer points of possible 28; %  
    Lab points of possible 28; %  
    Clinical points of possible 28; %  
             
  Time: out of possible 15 minutes        

STUDENT SIGNATURES INSTRUCTOR SIGNATURES
PEER: LAB:
STUDENT: CLINICAL: