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.
Mark one proficiency rating per skill based on your own current experience and competency.
1 = No experience 2 = Needs training 3 = Performs with supervision 4 = Performs independently
For each skill, mark one rating from 1 to 4. Rate specialized procedures only when relevant to your role and demonstrated competency.
Acute myocardial infarction (MI) 0★★★★−
Congestive heart failure (CHF) 0★★★★−
Post-cardiac catheterization care 0★★★★−
Post-cardiac / open-heart surgery care 0★★★★−
Aneurysm care 0★★★★−
Carotid endarterectomy care 0★★★★−
Post-vascular surgery care 0★★★★−
Heart transplant care 0★★★★−
Pacemaker management (temporary / permanent) 0★★★★−
Epicardial pacemaker management 0★★★★−
Sheath removal 0★★★★−
Heart sound assessment 0★★★★−
Pneumonia 0★★★★−
Respiratory distress assessment and response 0★★★★−
COPD management 0★★★★−
Breath sound assessment 0★★★★−
Post-thoracic surgery care 0★★★★−
Chest tube placement / management 0★★★★−
Tracheostomy management 0★★★★−
CPAP / BiPAP management 0★★★★−
Ventilation modes (AC / PC / SIMV / CPAP) 0★★★★−
Intubation / extubation care 0★★★★−
Arterial blood gas (ABG) interpretation 0★★★★−
Pulmonary embolism 0★★★★−
Tuberculosis precautions / care 0★★★★−
Stroke scale assessment 0★★★★−
Cerebrovascular accident (CVA) care 0★★★★−
Traumatic brain / spinal cord injury care 0★★★★−
Post-craniotomy care 0★★★★−
Seizure disorder management 0★★★★−
Mood disorder care 0★★★★−
Substance / alcohol withdrawal management 0★★★★−
Circulation and skin checks 0★★★★−
Continuous passive motion (CPM) devices 0★★★★−
Ambulation and assistive devices 0★★★★−
Prosthetic care 0★★★★−
Cast care 0★★★★−
Pin care 0★★★★−
Traction management 0★★★★−
Total joint replacement care 0★★★★−
Amputation care 0★★★★−
Wound care / wound VAC 0★★★★−
Pressure injury prevention 0★★★★−
Feeding / bariatric patient care 0★★★★−
GI bleeding 0★★★★−
Bowel obstruction 0★★★★−
GI surgery care 0★★★★−
Liver failure / liver disease 0★★★★−
Pancreatitis 0★★★★−
Post-liver transplant care 0★★★★−
Post-pancreas transplant care 0★★★★−
Renal failure 0★★★★−
Renal surgery care 0★★★★−
Renal transplant care 0★★★★−
Arteriovenous fistula / shunt care 0★★★★−
Three-way catheter and bladder irrigation 0★★★★−
Suprapubic catheter care 0★★★★−
Nephrostomy tube care 0★★★★−
Peritoneal dialysis 0★★★★−
Pre- / post-hemodialysis management 0★★★★−
Gynecological surgery care 0★★★★−
Blood glucose monitoring 0★★★★−
Diabetes management, including hypo-/hyperglycemic crisis 0★★★★−
IV insulin protocols 0★★★★−
Indwelling insulin pump management 0★★★★−
Pituitary disorder care 0★★★★−
Antiarrhythmics 0★★★★−
Anticoagulants (IV, oral, injection) 0★★★★−
Antidepressants 0★★★★−
Antihypertensives 0★★★★−
Antipsychotics 0★★★★−
Antiseizure medications 0★★★★−
Benzodiazepines 0★★★★−
Diuretics 0★★★★−
Emergency medications 0★★★★−
Epidural analgesia 0★★★★−
Inhaled medications 0★★★★−
Insulin 0★★★★−
Narcotic / opioid analgesics 0★★★★−
Nitrates (oral / topical) 0★★★★−
Non-opioid analgesics 0★★★★−
Oral hypoglycemic medications 0★★★★−
Patient-controlled analgesia (PCA) 0★★★★−
Procedural sedation administration 0★★★★−
Reversal agents 0★★★★−
Steroids (IV, oral, inhaled) 0★★★★−
Vasoactive drips: titration 0★★★★−
Vasoactive drips: management without titration 0★★★★−
Automated medication dispensing systems (Pyxis / Omnicell) 0★★★★−
Starting peripheral IVs 0★★★★−
Central line / implanted line care 0★★★★−
Central line blood draws 0★★★★−
Arterial line management 0★★★★−
TPN and lipid administration 0★★★★−
Blood product administration 0★★★★−
Chemotherapy administration / monitoring (if applicable) 0★★★★−
Placement of telemetry leads 0★★★★−
Dysrhythmia / rhythm interpretation 0★★★★−
Dysrhythmia management 0★★★★−
Obtaining a 12-lead ECG / EKG 0★★★★−
Interpretation of a 12-lead ECG / EKG 0★★★★−
Rapid response team activation / participation 0★★★★−
Cardioversion 0★★★★−
Defibrillation 0★★★★−
Malignant hyperthermia response 0★★★★−
National Patient Safety Goals / Core Measures 0★★★★−
Fall risk assessment and prevention 0★★★★−
Restraints / least-restrictive device use 0★★★★−
Patient and family education 0★★★★−
Age-specific / population-based care 0★★★★−
Isolation precautions 0★★★★−
Infection prevention 0★★★★−
Pain assessment and management 0★★★★−
Laboratory value interpretation and communication 0★★★★−
Specialty bed use 0★★★★−
Charge nurse experience 0★★★★−
Neonatal care (if applicable) 0★★★★−
Infant care 0★★★★−
Toddler care 0★★★★−
Preschool-age child care 0★★★★−
School-age child care 0★★★★−
Adolescent care 0★★★★−
Adult care 0★★★★−
Older adult / geriatric care 0★★★★−
Developmentally appropriate communication and education 0★★★★−
Age-specific vital signs and assessment 0★★★★−
Age-specific pain assessment 0★★★★−
Medication safety / dose considerations by age 0★★★★−
Fall and injury prevention by age group 0★★★★−
Cognitive, sensory, and functional needs across age groups 0★★★★−
Family / caregiver involvement appropriate to age and patient needs 0★★★★−
Electronic medical record (EMR) documentation 0★★★★−
Epic 0★★★★−
Cerner 0★★★★−
Eclipsys 0★★★★−
McKesson 0★★★★−
Meditech 0★★★★−
Other computerized clinical system (specify) 0★★★★−
Computerized physician order entry (CPOE) 0★★★★−
Barcode medication administration 0★★★★−
EMR conversion / transition support 0★★★★−
Other computerized clinical system (specify):
BLS
ACLS
PALS
PCCN
CCRN
Telemetry certificate / course
Other
