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.
Newborn/Neonate (birth to 30 days): 0★★★★−
Infant (1 month to 1 year): 0★★★★−
Toddler (1 year to 3 years): 0★★★★−
Preschooler (3 years to 5 years): 0★★★★−
School Age Child (5 years to 12 years): 0★★★★−
Adolescents (12 years to 18 years): 0★★★★−
Young Adults (18 years to 39 years): 0★★★★−
Middle Adults (39 years to 64 years): 0★★★★−
Older Adults (64 years to 79 years): 0★★★★−
Cardiopulmonary: 0★★★★−
Cath Lab: 0★★★★−
Lab: 0★★★★−
Long Term Care: 0★★★★−
Nursing: 0★★★★−
Home Health: 0★★★★−
Radiology: 0★★★★−
Therapy: 0★★★★−
Communicates effectively with residents, families, significant others, and other team members: 0★★★★−
Communicates effectively with peers, physicians, and State agencies: 0★★★★−
Coordinates resident care to the multidisciplinary team via meetings: 0★★★★−
Provides updated resident information to physicians, resident, family, legal, consultants, State agencies in accordance with regulations and/or standards: 0★★★★−
Knowledgeable and able to execute human resource policies as applicable to a variety of people issues: 0★★★★−
Delegates as appropriate: 0★★★★−
Actions demonstrate excellent customer service skills and builds relationships with families and associates: 0★★★★−
Assesses and monitor staff compliance of infection control and safety programs: 0★★★★−
Demonstrates excellent technical skills and judgement: 0★★★★−
Assesses and monitors accuracy and Facility Scorecard and CMS quality indicator data and initiates corrective action as indicated: 0★★★★−
Actively participates and contributes to facility meetings and process improvement activities: 0★★★★−
Promotes survey preparedness at all times: 0★★★★−
Demonstrates basic working knowledge of computer and modules and management reports: 0★★★★−
Demonstrates basic understanding of quality event investigating and reporting process: 0★★★★−
Knowledge of LTC Federal and state regulations including Medicare, Medicaid, and JCAHO as applicable: 0★★★★−
Ensure that RAI functions are completed timely for all residents: 0★★★★−
Provides and monitors the effectiveness of clinical orientation and ongoing training to all associates: 0★★★★−
Utilizes the nursing process to structure care to individuals resident's needs: 0★★★★−
Demonstrates the ability to assess and interpret data about the resident's status and ensure timely interventions are executed: 0★★★★−
Collaborates with DNS/Consultants on identified areas of noncompliance and implements necessary corrective actions: 0★★★★−
Effectively troubleshoots and ensures allocation of staffing resources to meet understanding of census, as it relates to HOL, expense control, budgeted PPD: 0★★★★−
Assesses and monitors discharge, rehospitalization patterns and implements corrective action as indicated: 0★★★★−
National Patient Safety Goals: 0★★★★−
Age Specific Care: 0★★★★−
Population Based Care: 0★★★★−
Automated Med Dispensing System: 0★★★★−
List Types:
Please list the EMR systems you have used: