Visual Urine Pregnancy Test Competency Assessment

 

Facility_________ Unit______________ Date__________________________

 

 

Name_________________________ Last 4 digits of SS#__________________

 

 

 

 

Yes

No

Does kit have to be refrigerated?

Does kit have to be freshly opened?

How many drops of urine are necessary to run the test?

□ 2 drops

□ 3 drops

How long do you wait until to read results?

□ 2 min

□ 3 min

Can you report the results on a patient (line S) when the internal positive control line C does not appear?

 

Is the negative internal control indicated by the absence of interfering background in the result well?

 

Does the internal positive control have to be confirmed and documented with each patient?

 

Does the internal negative control have to be confirmed and documented with each patient?

 

Do you have to change Quality Control sheets if the kits lot # changes?

 

Do you repeat the test using a new kit if the internal positive and/or internal negative controls failed?

 

 

 

 

 

 

Evaluated by_____________________

 

 

To be completed by evaluator:

 

 

Did the operator accurately interpret results?

Is the operator overall competent?

 

 

 

Comments/Corrective Action: