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Release Notes:
Data Element
Version 2010B

Data Element Name: Competency
Collected For: HCSS-3,
Definition:Documentation in personnel file that the employee’s clinical knowledge, experience, and capabilities are appropriate for assigned duties per the requirements of the minimum data set for competency.
Suggested Data Collection Question:Are the necessary sub-components of the minimum data set for this element present in the personnel file?
Allowable Values:

Yes    There is documentation in the personnel file demonstrating that the requirements of the minimum data set for this element have been met.

No   Documentation in the personnel file of the minimum data set requirements for this element is missing, incomplete, or expired.

Notes for Abstraction:None
Suggested Data Sources:

  • Clinical skills checklists / competency assessments
  • Continuing education credits
  • Documents that verify training and education
  • References from previous employers
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Personnel file documents must meet requirements as specified by the minimum data set for competency. Proof of appropriate competency includes the following components:
  • Verification of prior work experience in the profession assigned
  • Assessment of clinical skills and knowledge appropriate to the discipline and / or specialty at the time of hire / assignment, and annually thereafter
  • OSHA and HIPAA compliance training at the time of initial assignment then annually or as dictated per specific regulation
  • Current CPR card for those categories of employees required under state law to be certified in basic life support (e.g., RN, LPN / LVN, etc.)

  • None

Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)