Dialysis Technician Evaluation Form

LAGUNA DOCTORS HOSPITAL INC.
P. Guevara St. Sta. Cruz, Laguna
PERFORMANCE EVALUATION
(Hemodialysis Technician Evaluation Form)
Name: Date:
The competency areas in this checklist are organized under the framework of patient focused of care in
Hemodialysis settings.
Please check the level of expertise in each category.
5- very competent
4- competent and familiar with procedure
3- familiar with the procedure but require some assistance
2- need review and supervision
1- poor
1 2 3 4 5
I. ADHERENCE TO HOSPITAL POLICY
A. Follows the Hemodialysis Unit Protocol

B. Understands and follows the Patakaran sa Disiplina
II- WORKING REFORMANCE
Hemodialysis machine
A. Operates machine(priming, hooking and termination procedures)

B. Putting on bloodlines appropriately
C. Observes infection control in handling the machines and other
equipments
Pre- Dialysis assessment
A. Carefully check the hemodialysis mechanics and prescription.

B. Weigh the patient accurately, able to compute the ultrafiltration
rate and record
C. Do assessment of patient physical and neurological status
D. Check the vital signs taken by the Nurse On Duty (blood
pressure,pulse rate,respiratory rate and temperature) before
initiation of treatment.
SKILLS
A. Able to handle catheter access with all the precautions.

B. Handle all catheter and AV Fistula/Graft with aseptic technique.
C. Check the AV fistula/graft and catheter for good blood return or
blood flow to indicate that the placement is correct.
D. Do proper documentation of time the treatment has been initiated.
Intra- Dialysis Monitoring
A. Promote patient comfort during the procedure

B. Provide physical comfort measures by back care, elevate head of
the bed and assist in turning.
C. Maintain good outflow of blood.
D. Monitor alarms of machine and able to troubleshoot the
significance of alarm limits.
E. Do the regular rounds within the treatment area to detect early
machine problems.
F. Informs the nurses on duty regarding patient’s condition and

follows the nurses’ delegated task properly and promptly.
Post- Dialysis assessment
A. Performs treatment termination procedure properly.

B. Obtain patient weight and weight loss at the end of the treatment.
C. Provide health teaching and family education for the following
(patient diet, medications, care for the vascular access)
UNIT PREPARATION
A. Maintains the unit clean and orderly.

B. Follows housekeeping schedules given by the immediate superior.
C. Clean work surface after every treatment.
D. Strictly follows the general infection control in the unit.
III-WORKING KNOWLEDGE
A. Shows interest and Diligence in his duties

B. Has an initiative to perform other tasks when necessary
C. Cooperation and resourcefulness
D. Assertiveness/Motivation (desires to excel, works actively, takes
initiatively eagerly)
E. Notifies Supervisor when leaving assigned post/work area.
IV-DUTIES AND FUNCTIONS
A. Performs designated responsibilities

B. Prioritized needs of patients than other things
C. Provide safe and therapeutic environment
D. Carries program of work
E. Provide social, emotional, spiritual support
F. Give suggestions for the improvement of service
V-WORK ETHICS
A. Attendance
B. Creativity ( demonstrates initiative and provides suggestions for
new ideas to improve service)
C. Punctuality/dependability (can be depended on to complete
assignments)
D. Courtesy (refined, polite, good manners and right conduct)
E. Team work (demonstrate ability to work well with others and be a
contributing member of the team.
F. Public/human relations(manner of dealing with patient/hospital
staff/public)
G. Independence(is able to work without close supervision)
H. Work quality/judgment (accuracy, appropriateness, decision-
making)
I. Grooming
J. Stress tolerance
K. Respects and follows superiors order
Areas for improvement and goals:
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Remarks:
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Evaluator : ____________________________
Date of evaluation :______________________

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What are the competency areas evaluated in the performance evaluation?

What are the competency areas evaluated in the performance evaluation?

What are the steps involved in pre-dialysis assessment?

What are the steps involved in pre-dialysis assessment?

LAGUNA DOCTORS HOSPITAL INC.

P. Guevara St. Sta. Cruz, Laguna

Please check the level of expertise in each category.

A. Follows the Hemodialysis Unit Protocol

II- WORKING REFORMANCE

A. Operates machine(priming, hooking and termination procedures)

Pre- Dialysis assessment

A. Carefully check the hemodialysis mechanics and prescription.

A. Able to handle catheter access with all the precautions.

Intra- Dialysis Monitoring

A. Promote patient comfort during the procedure

F. Informs the nurses on duty regarding patient’s condition and

Post- Dialysis assessment

A. Performs treatment termination procedure properly.

A. Maintains the unit clean and orderly.

A. Shows interest and Diligence in his duties

IV-DUTIES AND FUNCTIONS

A. Performs designated responsibilities

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