Your name
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Last 4 Of SSN
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I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.
Instructions:This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Radiation Therapy
Skin Assessment: 0★★★★−
Total Body Irradiation: 0★★★★−
Side Effect Management: 0★★★★−
External Radiotherapy: 0★★★★−
Brachytherapy: 0★★★★−
Radiation Safety Precautions: 0★★★★−
Intraoperative Radiation: 0★★★★−
Oncology Patient Care
Renal Failure: 0★★★★−
Fever: 0★★★★−
Pneumonia: 0★★★★−
Cardiac Arrhythmias: 0★★★★−
Hypercalcemia: 0★★★★−
Hyperkalemia: 0★★★★−
Pancreatitis: 0★★★★−
Pulmonary Embolism: 0★★★★−
Bowel Obstruction: 0★★★★−
Diabetes: 0★★★★−
Pneumothorax: 0★★★★−
Stress Fractures: 0★★★★−
Respiratory Distress: 0★★★★−
Spinal Cord Compression: 0★★★★−
GI Bleed: 0★★★★−
Pleural Effusion: 0★★★★−
Infection: 0★★★★−
Hypokalemia: 0★★★★−
DIC: 0★★★★−
Atelectasis: 0★★★★−
Lymphedema: 0★★★★−
Vascular Devices
Flush Catheter: 0★★★★−
Punctured Catheter: 0★★★★−
Chemo Port: 0★★★★−
Omega-Port: 0★★★★−
S.E.A. Port: 0★★★★−
Port-A-Cath: 0★★★★−
Opti-Port: 0★★★★−
PICC Lines: 0★★★★−
Obtain Blood Specimens: 0★★★★−
Line Insertion Assistance: 0★★★★−
De-Clotting Ports: 0★★★★−
Groshong Catheters: 0★★★★−
Catheter Port: 0★★★★−
Site Care: 0★★★★−
Broviac Catheters: 0★★★★−
Patient/Teaching: 0★★★★−
Hickan Catheters: 0★★★★−
Care of Patients With
Foley Catheter Irrigations: 0★★★★−
CVP Line Insertion: 0★★★★−
Jejunostomy Tubes: 0★★★★−
Wound Care: 0★★★★−
Colostomy Care: 0★★★★−
TURP: 0★★★★−
Reverse Isolation: 0★★★★−
Liver Biopsy: 0★★★★−
Platelet Precautions: 0★★★★−
Accucheck: 0★★★★−
NG Tube Insertion: 0★★★★−
Suprapubic Catheter: 0★★★★−
Ileostomy: 0★★★★−
Thoracentesis: 0★★★★−
Isolation: 0★★★★−
Bone Marrow Biopsy: 0★★★★−
Enterostomal Care: 0★★★★−
Chest Tube Care: 0★★★★−
Paracentesis: 0★★★★−
Gastrostomy Tube: 0★★★★−
Narcotic Infusion: 0★★★★−
Hemodialysis: 0★★★★−
Nephrostomy Tube: 0★★★★−
Pain Management: 0★★★★−
Pulse Oximetry: 0★★★★−
Fistulas/Shunts: 0★★★★−
Seizure Precautions: 0★★★★−
Peritoneal Dialysis: 0★★★★−
Nasotracheal Suctioning: 0★★★★−
PCA Pumps: 0★★★★−
Cardiovascular
Hyperalimentation: 0★★★★−
Peripheral Blood Stem Cells: 0★★★★−
Packed RBC’s: 0★★★★−
IV Fluid Hydration: 0★★★★−
Venoclusive Disease: 0★★★★−
Fresh Frozen Plasma: 0★★★★−
Infections: 0★★★★−
Pneumonitis: 0★★★★−
Graft Rejection: 0★★★★−
Platelets: 0★★★★−
WBC/Lukocytes: 0★★★★−
Blood /Byproducts: 0★★★★−
Antivirals: 0★★★★−
Donor Education: 0★★★★−
Allogeneic BMT: 0★★★★−
Antibiotics: 0★★★★−
GVHD Graft: 0★★★★−
Autologous BMT: 0★★★★−
Antifungals: 0★★★★−
Implantable Infusion Pumps: 0★★★★−
Medtronic: 0★★★★−
Infusaid: 0★★★★−
Ambulatory Infusion Pumps: 0★★★★−
Synchormed: 0★★★★−
Cormed: 0★★★★−
Pharmacia: 0★★★★−
Auto Syringe: 0★★★★−
Pancretec: 0★★★★−
Patency Maintenance: 0★★★★−
Patient Teaching: 0★★★★−
Psycho & Social Care
Palliative Care: 0★★★★−
Hospice Care: 0★★★★−
Family Support: 0★★★★−
Counseling/Death/Dying: 0★★★★−
Identifying Support Groups: 0★★★★−
Advance Directives: 0★★★★−
Identifying Resources: 0★★★★−
Health Care Proxy: 0★★★★−
Pharmacology
Floxuridine/FUDR: 0★★★★−
Doxorubicin/Adriamycin: 0★★★★−
Heparin/Coumadin: 0★★★★−
Carmustine/BiCNU: 0★★★★−
Dopamine: 0★★★★−
Cisplatin: 0★★★★−
Mitomycin/Mustargen: 0★★★★−
Dilantin: 0★★★★−
Fluorouracil/-FU: 0★★★★−
Usulfan/Myleran: 0★★★★−
Neupogen/Epogen: 0★★★★−
Hydroxyurea/Hydrea: 0★★★★−
Corticosteroids: 0★★★★−
Vincristine/Oncovin: 0★★★★−
Methotrexate/Amethopterin: 0★★★★−
Morphine: 0★★★★−
Etoposide/VP-6-: 0★★★★−
Cyclophosphamide/Cytoxan: 0★★★★−
Decadron: 0★★★★−
Belomycin/Blenoxane: 0★★★★−
Vinblastine/Velban: 0★★★★−
Melphalan/Alkeran: 0★★★★−
IV Care/Skills: 0★★★★−
Chemotherapy Adm: 0★★★★−
IM/SQ: 0★★★★−
IVPB: 0★★★★−
IV Push/Intrathecal: 0★★★★−
Oncology & General Care
Thrombocytopenia: 0★★★★−
Stomatitis: 0★★★★−
Hemorrhage: 0★★★★−
Oncology PCU: 0★★★★−
Neuropathy: 0★★★★−
Bone Marrow Transplant: 0★★★★−
Death /Dying: 0★★★★−
Venous Access Devices: 0★★★★−
Electrolyte Imbalance: 0★★★★−
Palliative/Hospice Care: 0★★★★−
Neutropenia: 0★★★★−
Telemetry: 0★★★★−
Nutritional Needs: 0★★★★−
Immunosuppression: 0★★★★−
IV Maintenance: 0★★★★−
Septic Shock: 0★★★★−
Vomiting/Diarrhea/Nausea: 0★★★★−
Skin Care: 0★★★★−
Blood/Blood Byproducts: 0★★★★−
Normal Serum Labs Values: 0★★★★−
Radiation Therapy: 0★★★★−
Surgical Patient Care: 0★★★★−
Chemotherapy Protocols: 0★★★★−
Implantable Vascular Ports: 0★★★★−
Age Specific Competencies
Infant (Birth - 1 year): 0★★★★−
Preschooler (ages 2-5 years): 0★★★★−
Childhood (ages 6-12 years): 0★★★★−
Adolescents (ages 13-21 years): 0★★★★−
Young Adults (ages 22-39 years): 0★★★★−
Adults (ages 40-64 years): 0★★★★−
Older Adults (ages 65-79 years): 0★★★★−
Elderly (ages 80+ years): 0★★★★−
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