Please enable JavaScript in your browser to complete this form.Learner's Full Name *FirstLastLearner's Workplace *Mentor's Full Name *FirstLastMentor's Workplace *______________1. Patient Identification Explanation of process, patient consent obtainedMet (M)Needs to improve (NI)2. Blood bottles labelled and checked prior to blood sampling Met (M)Needs to improve (NI)3. Aware of procedure if labels not available Met (M)Needs to improve (NI)4. Equipment for preparing and caring for venous access site assembled correctly Met (M)Needs to improve (NI)5. Tourniquet used correctly and not left in situ for more than 1 minute at a timeMet (M)Needs to improve (NI)6. Obtained support from a more experienced practitioner appropriately Met (M)Needs to improve (NI)7. Untoward incident procedure managed (i.e vaso-vagal reaction)Met (M)Needs to improve (NI)8. Bleeding from site managed effectively Met (M)Needs to improve (NI)9. Appropriate action taken when patient reports pain during procedureMet (M)Needs to improve (NI)10. Managed patient fear/anxiety regarding process of venepuncture Met (M)Needs to improve (NI)11. Vacutainer and appropriate gauge needle usedMet (M)Needs to improve (NI)12. Alternate site required and accessed appropriately Met (M)Needs to improve (NI)13. Applied standard plasters, hypoallergenic plaster, gauze appropriately Met (M)Needs to improve (NI)14. All waste disposed of in accordance with employers policies Met (M)Needs to improve (NI)15. Blood sample and requested form completed fully. Patient held documentation completed where applicable Met (M)Needs to improve (NI)I, the candidate, now feel confident and competent enough to carry out venepuncture. Clear SignatureDate I, the mentor, am in agreement that the candidate is confident and competent to carry out venepuncture.Clear SignatureDateSubmit
