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Nursing Staff Qualifications Worksheet

SQE.1.1 Each staff member not permitted to practice independently has a job description

  • 1.1.1 Valid Job description

  • 1.1.2 Valid Addendum

  • 1.1.3 Signed Job description and addendum

SQE. 3.1 The hospital uses a defined process to match clinical staff knowledge, skills, and competency with patient needs

  • 1.1 Complete Summary Competency Checklist (signed and validated)

  • 1.2 Valid and complete competencies

  • 2. New clinical staff members are evaluated before or at the time they begin their work responsibilities ( Probationary Evaluation)

  • 3. There is at least one documented evaluation of each clinical staff defined by the hospital (Latest evaluation signed by UM)

SQE. 5

  • 1. Personnel files for each staff member are standardized and current and maintained and kept confidential according to hospital policy

2. Personnel files contain the qualifications and the work history of the staff member

  • 2.1 BSN/Diploma/ Master Degree - 100%

  • 2.2 License of Origin

  • 2.3 Previous Employment Certificate

  • 2.4 Latest Certificate of Employment

3. Personnel files contain the job description of the staff member when applicable

  • 3.1 Valid job description

  • 3.2 Valid Addendum

  • 3.3 Signed Job description and Addendum member

4. Personnel files contain a record of orientation to the hospital and the staff member’s specific role and in-service education attended by the staff member

  • 4.1 GNO/GSO

  • 4.2 In-Service education attended

  • 5. Personnel files contain the results of performance reviews ( Latest Evaluation signed by UM)

  • 6. Personnel files contain required health information (Records in Employee Health Services)

SQE. 8.1.1 1. Staff members who provide patient care, including physicians, are trained in at least basic life support (BLS)

  • 1.1 Valid BLS

  • 1.2 Valid PALS/ACLS if applicable

  • 1.3 Expired BLS/ACLS/PALS - Booking as evidence

2. There is evidence to show if a staff member passed the training

  • 2.1 Valid competencies and trainings

  • 2.2 MAHER Certificate of Completion: Simulation Based Competency Assessment and theoretical Exam

3. The desired level of training for each individual is repeated based on the requirements and/or time frames established by a recognized training program, or every two years if a recognized training program is not used

  • 3.1Valid competencies and trainings

  • 2.2 MAHER Certificate of Completion: Simulation Based Competency Assessment and theoretical Exam

SQE. 13

  • 1. The hospital has a standardized procedure to gather and document the education, certifications, and experience of each nursing staff member.

Education, training, and certifications are verified from the original source according to parameters found in the intent of SQE.9 and are documented.

  • 2.1 Primary Source Verification for Saudi only

  • 2.2 Dataflow

3. Licensure is verified from the original source according to the parameters found in the intent of SQE.9 and is documented

  • 3.1 Dataflow for License

  • 3.2 Saudi Council

  • 4. There is a record maintained of the credentials of every nursing staff member (Valid Credentialing Record)

SQE. 14.1

  • 1. Nursing staff participate in the hospital’s quality improvement activities evaluation signed by UM)

  • 2. The performance of individual nursing staff members is reviewed when indicated by the findings of quality improvement activities (latest evaluation signed by UM).

  • 3. Appropriate information from the review process is documented in the nurse’s personnel file or in a separate credential file (Valid Credentialing Record)


  • Comments/Suggestions

  • Auditor Name and Signature

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