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.
L and D 0★★★★−
LDRP 0★★★★−
Antepartum 0★★★★−
Mother Baby 0★★★★−
Diabetes 0★★★★−
Fetal Demise 0★★★★−
HELLP Syndrome 0★★★★−
Hyperemesis 0★★★★−
Immunologic Disorder 0★★★★−
Infectious Disease 0★★★★−
Multiple Gestation 0★★★★−
Placenta Previa/Abruptio 0★★★★−
Pre-Term Labor 0★★★★−
Premature Rupture of Membranes 0★★★★−
Conduct Stress Test 0★★★★−
Conduct Non-Stress Test 0★★★★−
Assist with External Version 0★★★★−
Assist with Umbilical Blood Sampling 0★★★★−
Use of Nitrazine/Fern Test 0★★★★−
Epidural Anesthesia 0★★★★−
General Anesthesia 0★★★★−
Spinal Anesthesia 0★★★★−
Response to Pain Management 0★★★★−
External 0★★★★−
IUPC Placement/Monitoring 0★★★★−
Spiral Electrode Placement 0★★★★−
Identify, Document & Treat Abnormal FHR Patterns 0★★★★−
Auscultate Fetal Heart Tones 0★★★★−
Determine Fetal Position 0★★★★−
Assess Contraction Characteristics 0★★★★−
Assess Status of Membranes 0★★★★−
Assess Station/Dilation/Effacement 0★★★★−
Positioning 0★★★★−
Leopold's Maneuver 0★★★★−
Assess for Reflexes/Clonus 0★★★★−
Bladder Catheterization 0★★★★−
Amnioinfusion (Assist or Perform) 0★★★★−
Recognize Complications of AROM 0★★★★−
Delivery Table Set Up 0★★★★−
Circulate Vaginal Delivery 0★★★★−
Circulate C - Section 0★★★★−
Scrub C - Section 0★★★★−
Radiant Warmer 0★★★★−
APGAR Scores 0★★★★−
Neonatal Vital Signs 0★★★★−
Neonatal Resuscitation 0★★★★−
Naso/Oropharyngeal Suctioning 0★★★★−
Bulb Syringe Suction 0★★★★−
Asthma 0★★★★−
Cardiac Disease 0★★★★−
Chorioamnionitis 0★★★★−
Pregnancy Induced Hypertension 0★★★★−
HELLP 0★★★★−
Hemolytic Anemia 0★★★★−
Hemorrhage 0★★★★−
HIV Positive 0★★★★−
HBV Disease 0★★★★−
Malpresentations 0★★★★−
Rh Disease 0★★★★−
Vaginal Delivery 0★★★★−
Cesarean Section 0★★★★−
Anesthesia - General 0★★★★−
Anesthesia - Spinal 0★★★★−
Bladder Distention 0★★★★−
Breast Milk Collection and Storage 0★★★★−
Breast Pump 0★★★★−
Breastfeeding - Latch Score 0★★★★−
Breastfeeding - Supplemental Feeding 0★★★★−
Breastfeeding Support 0★★★★−
Contraceptive Education 0★★★★−
Epidural/PCA 0★★★★−
Homan's Sign 0★★★★−
Multiple Births 0★★★★−
Parent/Infant Interaction/Attachment 0★★★★−
Post Partum Hemorrhage 0★★★★−
Antibiotics/Antivirals 0★★★★−
Antihypertensives 0★★★★−
Antiseizure 0★★★★−
Betamethasone 0★★★★−
Insulin 0★★★★−
Magnesium Sulfate 0★★★★−
Methergine 0★★★★−
Opioids and Reversal Agents 0★★★★−
Pitocin 0★★★★−
Terbutaline 0★★★★−
Start Ivs 0★★★★−
IV Management 0★★★★−
Blood Product Administration 0★★★★−
Newborn Assessment 0★★★★−
Infant Vital Signs 0★★★★−
Ballard Scale/Dubowitz 0★★★★−
Car Seat Education 0★★★★−
Circumcision Care/Teach to Parents 0★★★★−
Cord Care/Teach to Parents 0★★★★−
Immunizations - Infant 0★★★★−
Infant Caretaking Skills 0★★★★−
Infant Identification and Security 0★★★★−
Metabolic Screen 0★★★★−
Jaundice/Bilirubin 0★★★★−
Phototherapy 0★★★★−
Thermoregulation 0★★★★−
National Patient Safety Goals/Core Measures 0★★★★−
Experience in a "Baby Friendly" Facility 0★★★★−
Fall Risk Assessment/Prevention 0★★★★−
Restraints/Use of Least Restrictive Device 0★★★★−
Parent/Family Teaching 0★★★★−
Age Specific/Population-Based Care 0★★★★−
Isolation Precautions 0★★★★−
Infection Prevention 0★★★★−
Charge Experience 0★★★★−
Interpretation and Communication of Lab Values 0★★★★−
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★★★★−
EMR Conversion YesNo
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★★★★−
