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Student's Name: ____________________

Grade (circle one):

P = achieved 3 or above in all categories

F = achieved 2 or below in one or more categories

The following scale is utilized:

ACTION	S	G	SA	U	F
Gather the supplies	5	4	3	2	1
Explain the procedure to the patient	5	4	3	2	1
Wash and dry hands carefully	5	4	3	2	1
Go to and stand as close as possible at the side of the bed from which the patient will be transferred to a chair	5	4	3	2	1
Place the chair close and parallel to the bed, allowing adequate space to maneuver the Hoyer lift	5	4	3	2	1
Lock the wheels of the bed	5	4	3	2	1
Raise the bed to waist level and remove the pillow out from under the patient's head and neck	5	4	3	2	1
Lower the siderail nearest you	5	4	3	2	1
Fold the top linens down past the patient's feet	5	4	3	2	1
Move the patient in segments to the side of the bed	5	4	3	2	1
Turn the patient to a lateral position away from you	5	4	3	2	1
Place the Hoyer lift hammock on the bed against the patient's back with the narrow piece (if present) near his/her shoulders and the wide piece (if present) near his/her knees	5	4	3	2	1
Vertically fanfold the distal part of the Hoyer lift hammock up to the center of the bed as close to the patient as possible	5	4	3	2	1
Assist the patient to roll over the fanfolded Hoyer lift hammock to a lateral position facing towards you	5	4	3	2	1
Raise the siderail	5	4	3	2	1
Move to and stand at the other side of the bed and lower the siderail	5	4	3	2	1
Grasp the Hoyer lift hammock and pull gently to remove any wrinkles	5	4	3	2	1
Assist the patient to a supine position in the center of the Hoyer lift hammock	5	4	3	2	1
Raise the siderail	5	4	3	2	1
Move to and stand at the other side of the bed near the chair and Hoyer lift and lower the siderail	5	4	3	2	1
Position the base of the Hoyer lift under the bed	5	4	3	2	1
Lock the wheels of the Hoyer lift	5	4	3	2	1
Lower the boom of the Hoyer lift slowly, by turning the hydraulic valve to the left (counterclockwise), until it is close to the patient's chest	5	4	3	2	1
Lock the hydraulic valve, by turning the hydraulic valve to the right (clockwise), when it is close to the patient's chest	5	4	3	2	1
Attach the hooks with the short chains to the top holes (on the narrow piece if present) on the Hoyer lift hammock	5	4	3	2	1
Attach the hooks with the long chains to the bottom holes (on the wide piece if present) on the Hoyer lift hammock	5	4	3	2	1
Have the patient fold his/her arms across his/her chest	5	4	3	2	1
Pump the pump (hydraulic) handle of the Hoyer lift using long, slow, even strokes until the patient is raised up off the bed	5	4	3	2	1
Unlock the wheels of the Hoyer lift	5	4	3	2	1
Use the steering handle of the Hoyer lift to pull it out from under the bed	5	4	3	2	1
Roll and steer the base of the Hoyer lift toward the chair to which the patient will be transferred	5	4	3	2	1
Spread the base of the Hoyer lift to clear the chair, by moving the adjusting lever handle to the right, as necessary	5	4	3	2	1
Assure that the patient is centered directly over the chair to which he/she will be transferred	5	4	3	2	1
Release the hydraulic valve slowly, by turning it to the left (counterclockwise), to lower the boom of the Hoyer lift and gently guide the patient into the chair to which he/she will be transferred	5	4	3	2	1
Close the hydraulic valve, by turning it to the right (clockwise), as soon as the boom of the Hoyer lift has lowered and you have gently guided the patient into the chair to which he/she will be transferred	5	4	3	2	1
Dettach the hooks with the short chains from the top holes (on the narrow piece if present) on the Hoyer lift hammock	5	4	3	2	1
Dettach the hooks with the long chains from the bottom holes (on the wide piece if present) on the Hoyer lift hammock	5	4	3	2	1
Remove the Hoyer lift out from around the chair	5	4	3	2	1
Assess and adjust the patient's alignment in the chair and secure him/her with a seat belt in the back of the chair as necessary	5	4	3	2	1
Assure the patient's call light is readily available	5	4	3	2	1
Wash and dry hands carefully	5	4	3	2	1
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