Staff member’s name: Unit:

Staff member’s role/employee number: Date:

Competency Statement: The perioperative RN has met the requirements for competency validation to perform hand hygiene in the perioperative setting.1
1. Recommended practices for hand hygiene in the perioperative setting. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:75-81.

The applicable PNDS domains, diagnoses, and outcomes link to the PNDS Interventions/Performance Criteria, which include assessment, implementation, and evaluation.
|PNDS Domains:2 Safety |PNDS Diagnoses (potential):2 Risk for infection |
| |Delayed surgical recovery |
|PNDS Patient Outcomes:2 Patient is free from signs and symptoms of infection. |
| |

2. Petersen C, ed. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN, Inc; 2010. In press.

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Select the applicable developmental stages and age groups:3
|♦ Applicable to all developmental stages |
|♦ Infant (ie, birth to 18 months) |♦ Adolescent (ie, 13 years to 18 years) |
|♦ Early childhood (ie, 18 months to 3 years) |♦ Young adulthood (ie, 18 years to 35 years) |
|♦ Play age (ie, 3 years to 5 years) |♦ Middle adulthood (ie, 36 years to 55 or 65 years) |
|♦ School age (ie, 6 years to 12 years) |♦ Late adulthood (ie, 55 or 65 years to death) |

3. Harder AF. The developmental stages of Erik Erikson. LearningPlaceOnline.com. http://www.learningplaceonline.com/stages/organize/Erikson.htm. Accessed June 10, 2009.

Select the applicable vulnerable/diverse populations:4
|♦ Applicable to all populations |
|♦ Underserved populations (eg, homeless, single mothers, low socioeconomic status) |♦ Cognitively impaired (eg, obsessive compulsive disorder, attention deficit disorder, borderline personality |
| |disorder) |
|♦ Cultural considerations (eg, ethnicity, spiritual) |♦ Physically impaired (eg, hearing, vision, mobility)