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
Work Settings:
General Acute Care: 0★★★★−
Home Health: 0★★★★−
Nursing Home: 0★★★★−
Outpatient Clinic: 0★★★★−
Pediatric Rehab: 0★★★★−
Acute Rehab Hospital: 0★★★★−
Rehab Unit in Hospital: 0★★★★−
Neuro:
Cerebral Vascular Accident: 0★★★★−
Coma Patients: 0★★★★−
Head Trauma: 0★★★★−
Spinal Cord Injury: 0★★★★−
Parkinson’s Disease: 0★★★★−
Traumatic Brain Injury: 0★★★★−
Neuromuscular Disease: 0★★★★−
Post Craniotomy: 0★★★★−
Bowel/Bladder Programs: 0★★★★−
Ortho:
Arthritis Programs: 0★★★★−
Back Syndrome: 0★★★★−
Cervical Traction: 0★★★★−
Continuous Passive Motion Machine N/A 0★★★★−
Gait Training: 0★★★★−
Hand Injury: 0★★★★−
Hip Fractures: 0★★★★−
Care of Patient with Halo: 0★★★★−
Hot/Cold Packs: 0★★★★−
Mobilization Techniques: 0★★★★−
Neck Injuries: 0★★★★−
TMJ Dysfunction: 0★★★★−
Total Hip Replacement: 0★★★★−
Total Knee Replacement: 0★★★★−
Pulmonary:
Assessment of breath sounds: 0★★★★−
Chest Physiotherapy: 0★★★★−
Oximetry: 0★★★★−
Nasal cannula: 0★★★★−
Face Mask: 0★★★★−
Portable O2 tank: 0★★★★−
Nasotracheal Suctioning: 0★★★★−
Tracheal Suctioning: 0★★★★−
Care of patient w/Mechanical Vent: 0★★★★−
COPD: 0★★★★−
Pediatrics:
Cerebral Palsy: 0★★★★−
Activities of Daily Living: 0★★★★−
Learning Disabilities: 0★★★★−
Orthotics: 0★★★★−
Spina Bifida: 0★★★★−
Autism: 0★★★★−
AK Prosthetics: 0★★★★−
Amputees: 0★★★★−
BK Prosthetics: 0★★★★−
Bracing/Joint Immobilization: 0★★★★−
Resting Splints: 0★★★★−
Casts/Check for Circulation: 0★★★★−
Upper Extremity Prosthetics: 0★★★★−
Nutritional Requirements:
Thickened Liquids: 0★★★★−
Minimal: 0★★★★−
Thick: 0★★★★−
Extra Thick: 0★★★★−
Pudding Thick: 0★★★★−
NG Tubes: 0★★★★−
Peg Tubes: 0★★★★−
Restraints:
4pt: 0★★★★−
Shoulder Strap: 0★★★★−
Hand Mitts: 0★★★★−
Wrist: 0★★★★−
Ankle: 0★★★★−
Pelvic Strap: 0★★★★−
EMR:
Epic: 0★★★★−
Cerner: 0★★★★−
Eclipsys: 0★★★★−
McKesson: 0★★★★−
Meditech: 0★★★★−
Other Computerized System: 0★★★★−
Computerized Physician Order Entry: 0★★★★−
Bar Coding for Medication Administration: 0★★★★−
Other:
Ability to evaluate and assign Functional Independence Score: 0★★★★−
AIDS Patients: 0★★★★−
Burn Management: 0★★★★−
Cardiac Rehabilitation: 0★★★★−
Function Capacity Evaluation: 0★★★★−
Geriatrics: 0★★★★−
Manual Therapy: 0★★★★−
Massage Therapy: 0★★★★−
Muscle Stimulation: 0★★★★−
Pain Management/Giving Meds: 0★★★★−
Physical Capacity: 0★★★★−
Pulmonary Rehab: 0★★★★−
Sterilization Technique: 0★★★★−
TENS: 0★★★★−
Wound Debridement/Dressing Change: 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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