Your name
Your Email
Last 4 Of SSN
Date
E-Signature
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
Patient Rights
Communicates and obtains information while respecting rights and privacy in accordance with HIPAA: 0★★★★−
Involves patient and family respecting their role including Advance Directives: 0★★★★−
Complies with nursing staff responsibility related to Organ Donation: 0★★★★−
Meets patient and family needs regarding communication including interpreter services: 0★★★★−
Provides accurate information to patients and families timely: 0★★★★−
Vital Signs and Weights
Obtaining and Recording
BP, including Orthostatic: 0★★★★−
Pulse, Radial: 0★★★★−
Temperature, Oral: 0★★★★−
Temperature, Rectal: 0★★★★−
Temperature, Axillary: 0★★★★−
Temperature, Tympanic: 0★★★★−
Respirations: 0★★★★−
Weight, Pounds and Kilograms: 0★★★★−
Recognizing Cardiac Arrest: 0★★★★−
Activating Code Team: 0★★★★−
Bringing Emergency Equipment to Room: 0★★★★−
Providing Appropriate Code Support: 0★★★★−
Use of Electronic VS equipment - Automatic BP machine (Dynamap): 0★★★★−
Electronic Thermometer: 0★★★★−
Applying Oximeter: 0★★★★−
Scale Use
Standing Scale: 0★★★★−
Chair Scale: 0★★★★−
Bed Scale: 0★★★★−
GI/GU Report Abnormal Findings: 0★★★★−
Bowel Function: 0★★★★−
Bladder Function: 0★★★★−
Administering Enemas - Tap Water: 0★★★★−
Fleets: 0★★★★−
Return Flow: 0★★★★−
Bed Pan and Catheters
Placing and Removing Bed Pan: 0★★★★−
Clamping Catheter: 0★★★★−
Emptying Foley Bag: 0★★★★−
Placing Condom Catheter: 0★★★★−
Emptying and Replacing Ostomy Bag (Established Ostomy): 0★★★★−
Nutrition
Estimating Intake: 0★★★★−
Setting up for Meals: 0★★★★−
Feeding Patients: 0★★★★−
Aspiration Precautions: 0★★★★−
Nourishments: 0★★★★−
Counting Calories: 0★★★★−
Fluid Restriction: 0★★★★−
NPO: 0★★★★−
Specimens
Collecting Stool: 0★★★★−
Collecting Sputum: 0★★★★−
Labeling Specimens and Preparing for Transport: 0★★★★−
Collecting Urine
Clean Catch: 0★★★★−
24 Hour: 0★★★★−
Hygiene / Skin
Risk Factors for Skin Breakdown: 0★★★★−
Observing Pressure Points for Redness or Breakdown: 0★★★★−
Bathing / Daisy Hygiene
Bathing (Shower / Tub / Arjo): 0★★★★−
Oral Care, including Patients who are NPO or Comatose: 0★★★★−
Pen Care: 0★★★★−
Foot Care for Patients with Impaired Circulation or Sensation: 0★★★★−
Incontinence Care: 0★★★★−
Shaving and Precautions: 0★★★★−
Reducing Pressure and Friction: 0★★★★−
Use of Pressure and Friction Reduction Devices
Special Beds / Mattresses: 0★★★★−
Heels and Elbow Protection: 0★★★★−
Foot Cradles: 0★★★★−
Use of Shower Chair: 0★★★★−
Use of Bath / Shower Boat: 0★★★★−
Infection Control
Reverse Isolation: 0★★★★−
Body Substance Isolation: 0★★★★−
TB Precautions: 0★★★★−
MRSA Precautions: 0★★★★−
Hand Washing: 0★★★★−
Infectious / Hazardous Waste Disposal: 0★★★★−
Supply / Equipment Disposal: 0★★★★−
Use of Disposable Thermometer: 0★★★★−
Use of CPR Mask / Bag: 0★★★★−
Proper Use of Specific Barrier Methods
Gloves: 0★★★★−
Gown: 0★★★★−
Mask / Goggles: 0★★★★−
Safety and Activity
Determining Patient ID: 0★★★★−
Identifying Safety Hazards: 0★★★★−
Determining Need for Additional Help: 0★★★★−
Assessing Safety and ADL Needs: 0★★★★−
Recognizing Abuse: Substance, Physical, Emotional, etc: 0★★★★−
Maintaining Clean, Orderly Work Area: 0★★★★−
Disposing of Sharps: 0★★★★−
Handling Hazardous Materials: 0★★★★−
Proper Body Mechanics: 0★★★★−
ROM Exercises: 0★★★★−
Transferring to Bed, WC, Commode, etc: 0★★★★−
Turning and Positioning: 0★★★★−
Patient Safety Module: 0★★★★−
Reporting Broken Equipment: 0★★★★−
Responding to Safety Hazards: 0★★★★−
Use of HoyerLift (Dextra /Maxi): 0★★★★−
Bed Operation: 0★★★★−
Use of Wheel Locks: 0★★★★−
Use of Alarms: Bed, Patient, Unit: 0★★★★−
Use of Call Light: 0★★★★−
Documenting Use of Restraints: 0★★★★−
Use of Transfer Belt: 0★★★★−
Use of Gait Belt for Ambulation: 0★★★★−
Use of Seizure Pads: 0★★★★−
Application of Restraints
Belt including seat belt: 0★★★★−
Wrist/Ankle: 0★★★★−
Vest: 0★★★★−
Care Routines
New Admissions and Transfers
Inventory and Disposition of Belongings, Use of Checklist: 0★★★★−
Room Orientation, Call Bell: 0★★★★−
Post-op Patients
Transferring into Bed: 0★★★★−
Call Bell: 0★★★★−
Assist with Turns: 0★★★★−
Maintaining O2 Therapy: 0★★★★−
Preparation For and Transfer to SNF
Early Bath: 0★★★★−
Preparing Belongings: 0★★★★−
Preparing for and Explaining Routines to Patient: 0★★★★−
Post Mortem Care: 0★★★★−
Use of Incentive Spirometer: 0★★★★−
Removing / Replacing
Antiembolic Stockings: 0★★★★−
Sequential Stockings: 0★★★★−
Communication
Using Appropriate Abbreviations: 0★★★★−
Identifying Unusual Patient Incidents that Require Reporting: 0★★★★−
Reinforcing RN Teaching With Patient: 0★★★★−
Selecting and Using Forms Appropriately: 0★★★★−
Using Alternate Communication Tools / Devices: 0★★★★−
Communicating to RN: Changes in Patient Condition: 0★★★★−
Communicating to RN: Patient Needs, Complaints and Concerns: 0★★★★−
Communicating to RN: Unusual Incidents: 0★★★★−
Recording and Reporting: Vital Signs: 0★★★★−
Recording and Reporting: Bathing / Hygiene: 0★★★★−
Recording and Reporting: Turning and Repositioning: 0★★★★−
Recording and Reporting: Ambulation and Activity: 0★★★★−
Recording and Reporting: Diet Intake, Calorie Count: 0★★★★−
Recording and Reporting: Bowel Movements: 0★★★★−
Recording and Reporting: I & O: 0★★★★−
Recording and Reporting: Shift Volumes and Totals: 0★★★★−
Recording and Reporting: Marking and/or Measuring Amount of Urine, Gastric Fluid, NG Drainage, Emesis, Diarrhea: 0★★★★−
Unit Activity
Identifying Unusual Incidents on the Unit that Require Reporting: 0★★★★−
Locating and Using Appropriate Reference Materials: 0★★★★−
Charging for Patient Care Items: 0★★★★−
Completing Risk Management Reports as Needed: 0★★★★−
Obtaining Needed Supplies and Equipment: 0★★★★−
Reporting and Following up on Faulty Equipment and Supplies: 0★★★★−
Using Telephone System: 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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