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
GENERAL NURSING
ADMIT / ORIENT VOLUNTARY CLIENTS: 0★★★★−
ADMIT / ORIENT INVOLUNTARY CLIENTS: 0★★★★−
INITIAL COMPREHENSIVE ASSESSMENT: 0★★★★−
INITIAL FOCUSED ASSESSMENT: 0★★★★−
INITIAL SCREENING ASSESSMENT: 0★★★★−
INITIATE CARE PLAN: 0★★★★−
REASSESSMENT / UPDATE CARE PLAN: 0★★★★−
MULTI-DISCIPLINARY PLANNING: 0★★★★−
SUPERVISE UNLICENSED PERSONNEL: 0★★★★−
VITAL SIGN MONITORING: 0★★★★−
FULL RESTRAINTS: 0★★★★−
WRIST RESTRAINTS: 0★★★★−
AMBULATORY CUFFS: 0★★★★−
ADMIN / MONITOR TUBE FEEDINGS: 0★★★★−
INSERT / CARE OF FOLEY CATHETER: 0★★★★−
ASSIST WITH LUMBAR PUNCTURE: 0★★★★−
ISOLATION TECHNIQUES: 0★★★★−
ADVANCE DIRECTIVES: 0★★★★−
PATIENT TEACHING: 0★★★★−
CASE MANAGER: 0★★★★−
DISCHARGE PLANNING: 0★★★★−
DISCHARGE CLIENTS: 0★★★★−
CULTURAL DIVERSITY: 0★★★★−
ETHNIC AWARENESS: 0★★★★−
FORENSIC NURSE: 0★★★★−
CARE OF PSYCH DISORDERS
SCHIZOPHRENIA: 0★★★★−
PARANOID PSYCHOTIC DISORDER: 0★★★★−
CATATONIC PSYCHOTIC DISORDER: 0★★★★−
HALLUCINATIONS: 0★★★★−
BIPOLAR DISORDER: 0★★★★−
DEPRESSION: 0★★★★−
SUICIDAL IDEATION / ATTEMPTS: 0★★★★−
DELUSIONAL DISORDERS: 0★★★★−
ANXIETY DISORDERS: 0★★★★−
PANIC ATTACKS: 0★★★★−
PHOBIAS: 0★★★★−
OBSESSIVE / COMPULSIVE DISORDER: 0★★★★−
DISSOCIATIVE IDENTITY DISORDER: 0★★★★−
SEXUAL DISORDERS: 0★★★★−
SEXUAL ABUSE / ASSAULT: 0★★★★−
SURVIVOR OF ABUSE / VIOLENCE: 0★★★★−
POST TRAUMATIC STRESS DISORDER: 0★★★★−
SOMATOFORM DISORDERS (PAIN ETC.): 0★★★★−
MENTAL RETARDATION: 0★★★★−
ADHD: 0★★★★−
DEVELOPMENTAL / AUTISTIC DISORDERS: 0★★★★−
COGNITIVE DISORDERS
DELIRIUM: 0★★★★−
DEMENTIA: 0★★★★−
ALZHEIMER'S (DEMENTIA): 0★★★★−
AMNESTIC DISORDERS: 0★★★★−
PERSONALITY DISORDERS
CLUSTER A - PARANOID / SCHIZOID: 0★★★★−
CLUSTER B - ANTISOCIAL / BORDERLINE: 0★★★★−
CLUSTER C - ANXIOUS / FEARFUL: 0★★★★−
EATING DISORDERS
ANOREXIA NERVOSA: 0★★★★−
BULIMIA NERVOSA: 0★★★★−
OBESITY: 0★★★★−
SUBSTANCE RELATED DISORDERS
ALCOHOL -RELATED: 0★★★★−
DRUG -RELATED: 0★★★★−
INTERVENTIONS / THERAPIES
CRISIS INTERVENTION: 0★★★★−
THERAPEUTIC COMMUNICATION: 0★★★★−
THERAPEUTIC MILIEU: 0★★★★−
EDUCATION OR VOCATIONAL TRAINING: 0★★★★−
DRUG & ALCOHOL EDUCATION: 0★★★★−
ELECTROCONVULSIVE THERAPY: 0★★★★−
ALTERNATIVE THERAPIES
BIOFEEDBACK: 0★★★★−
GUIDED IMAGERY: 0★★★★−
EXPRESSIVE THERAPY (ART, MOVEMENT): 0★★★★−
MASSAGE THERAPY: 0★★★★−
MEDITATION: 0★★★★−
RECREATIONAL THERAPY: 0★★★★−
THERAPEUTIC TOUCH: 0★★★★−
CONDUCTING PSYCHOTHERAPY
INDIVIDUAL: 0★★★★−
GROUP: 0★★★★−
COUPLE / FAMILY: 0★★★★−
BEHAVIORAL: 0★★★★−
MEDS / IV THERAPY
MEDS SIDE EFFECTS - RECOGNITION AND MANAGEMENT
AGE APPROPRIATE CARE
NEWBORN (BIRTH-30 DAYS): 0★★★★−
INFANT (30 DAYS - 1 YEAR): 0★★★★−
TODDLER (1 - 3 YEARS): 0★★★★−
PRESCHOOLER (3 - 5 YEARS): 0★★★★−
SCHOOL AGE (5 - 12 YEARS): 0★★★★−
ADOLESCENTS (12 - 18 YEARS): 0★★★★−
YOUNG ADULTS (18 - 39 YEARS): 0★★★★−
MIDDLE ADULTS (39 - 64 YEARS): 0★★★★−
OLDER ADULTS (64+ YEARS): 0★★★★−
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