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
Duties
Awareness of HCAHPS: 0★★★★−
Administrative procedures: 0★★★★−
MDS Coordinator Admit/discharge patients: 0★★★★−
Blood glucose monitoring: 0★★★★−
Coordinate scheduling: 0★★★★−
Documentation: 0★★★★−
Dressing changes: 0★★★★−
Familiarity with advanced directives: 0★★★★−
HIPPA regulations: 0★★★★−
Isolation techniques: 0★★★★−
Observe for adverse medication reaction: 0★★★★−
Alert licensed staff of medication reaction: 0★★★★−
Patient education: 0★★★★−
Position/transfer patients: 0★★★★−
Prepare reports: 0★★★★−
Pulse oximetry: 0★★★★−
Lab draw: 0★★★★−
Screen/direct provider calls: 0★★★★−
Screen/direct patient calls: 0★★★★−
Urine dipstick: 0★★★★−
Universal precautions: 0★★★★−
Vital signs: 0★★★★−
Wound care: 0★★★★−
Assist with
Patient's health history: 0★★★★−
Patient's physical exam: 0★★★★−
Patient procedures: 0★★★★−
Diagnostic testing and procedures: 0★★★★−
Discharge instructions: 0★★★★−
Therapeutic procedures: 0★★★★−
Cardiac
Assist with emergency: 0★★★★−
Perform 12 lead EKG: 0★★★★−
Use of cardiac monitor: 0★★★★−
Vascular
Apply/monitor noninvasive BP monitor: 0★★★★−
Intake and output: 0★★★★−
Discontinue peripheral IV: 0★★★★−
Manual BP: 0★★★★−
Phlebotomy draws: 0★★★★−
Pulmonary
Apply nasal cannula/face mask: 0★★★★−
Incentive spirometry: 0★★★★−
O2 saturation monitor: 0★★★★−
Neurology
Assist with lumbar puncture: 0★★★★−
Neurological evaluation: 0★★★★−
Seizure precautions: 0★★★★−
Orthopedic
Cast care: 0★★★★−
Crutch walking: 0★★★★−
Traction: 0★★★★−
Gastrointestinal
Assist with feeding: 0★★★★−
Nutritional evaluation: 0★★★★−
Instruct/obtain clean catch urine: 0★★★★−
Straight/Foley catheter female: 0★★★★−
Straight/Foley catheter male: 0★★★★−
Medication Administration
Vitamins, minerals, herbs: 0★★★★−
Antibiotics: 0★★★★−
Antifungal: 0★★★★−
Antiviral: 0★★★★−
Psychotropic: 0★★★★−
Ophthalmic medications: 0★★★★−
Aural medications: 0★★★★−
Respiratory system medications: 0★★★★−
Cardiovascular system medications: 0★★★★−
Gastrointestinal system medications: 0★★★★−
Urinary system medications: 0★★★★−
Reproductive system medications: 0★★★★−
Endocrine system medications: 0★★★★−
Musculoskeletal system medications: 0★★★★−
Nervous system medications: 0★★★★−
Immunizations: 0★★★★−
Intramuscular (IM): 0★★★★−
Subcutaneous (SQ): 0★★★★−
Intradermal: 0★★★★−
Z-track: 0★★★★−
Age Specific Competencies
Newborn/neonate (birth-30 days): 0★★★★−
Infant (31 days-1 year): 0★★★★−
Toddler (ages 2-3 years): 0★★★★−
Preschool (ages 4-5 years): 0★★★★−
School age (ages 6-12 years): 0★★★★−
Adolescent (ages 13-21 years): 0★★★★−
Young adult (ages 22-39 years): 0★★★★−
Adult (ages 40-64 years): 0★★★★−
Older adult (ages 65-79 years): 0★★★★−
Elderly (ages 80+ years): 0★★★★−
Please list any Additional Skills
Additional Skill 1:
Additional Skill 2:
Additional Skill 3:
Additional Skill 4:
Additional training
Training 1:
Training 2:
Training 3:
Training 4:
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