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.
Open Heart Recovery 0★★★★−
AAA Repair 0★★★★−
Vascular Surgery 0★★★★−
Pacemaker - Permanent & Temporary 0★★★★−
Cardioversion 0★★★★−
AICD Insertion 0★★★★−
Cardiac Arrest 0★★★★−
Cardiac Tamponade 0★★★★−
CHF/Pulmonary Edema 0★★★★−
Abnormal Heart Sounds/Murmurs 0★★★★−
Pulses/Circulation Checks 0★★★★−
Ventilator Management 0★★★★−
Fresh Tracheostomy 0★★★★−
Thoracotomy/Lobectomy/Pneumonectomy 0★★★★−
Pneumothorax/Hemothorax 0★★★★−
Laryngospasm 0★★★★−
Pulmonary Embolism 0★★★★−
COPD 0★★★★−
ABG Interpretation 0★★★★−
Post Craniotomy 0★★★★−
Anterior/Posterior Spinal Fusion 0★★★★−
Carotid Endardarectomy 0★★★★−
Spine Surgery 0★★★★−
CVA 0★★★★−
Stroke Scale 0★★★★−
Glascow Coma Scale 0★★★★−
Spinal Precautions 0★★★★−
Hypothermia Protocol 0★★★★−
Hypo/Hyperthermia Blanket 0★★★★−
Sedation Scales/Levels 0★★★★−
Pancreas/Liver Transplant 0★★★★−
Colon Surgery 0★★★★−
Colostomy/Ileostomy 0★★★★−
ERCP 0★★★★−
G Tube/J Tube Management 0★★★★−
T Tube Management 0★★★★−
Renal Surgery 0★★★★−
TURP 0★★★★−
Arteriovenous Fistula/Shunt 0★★★★−
Nephrostomy Tubes 0★★★★−
Diabetes - Hypo/Hyperglycemic Crisis 0★★★★−
IV Insulin Protocols 0★★★★−
Laminectomy 0★★★★−
Total Joint Replacement 0★★★★−
Amputation 0★★★★−
Open Reduction/Internal Fixation 0★★★★−
General Orthopedic Surgeries 0★★★★−
CPM/Traction 0★★★★−
Circulation Checks 0★★★★−
Surgical Drains 0★★★★−
Wound Vac 0★★★★−
Surgical Wound Assessment 0★★★★−
Skin Assessment for Breakdown 0★★★★−
Staging Decubitus Ulcers 0★★★★−
Procedural Sedation 0★★★★−
Anesthesia Medications 0★★★★−
Anti-Arrhythmics 0★★★★−
Anticoagulants 0★★★★−
Anti-Hypertensives 0★★★★−
Anti-Seizure Medications 0★★★★−
Benzodiazepines 0★★★★−
Emergency Medications 0★★★★−
Insulin 0★★★★−
Narcotics/Opioid Analgesics 0★★★★−
Nitrates 0★★★★−
Non-Opioid Analgesics 0★★★★−
Reversal Agents 0★★★★−
Steroids 0★★★★−
Automated Medication Dispensing (Pyxis, Omnicell) 0★★★★−
Starting IVs 0★★★★−
Central Line Blood Draws 0★★★★−
Central Line/Implanted Line Care 0★★★★−
Blood Product Administration 0★★★★−
Malignant Hyperthermia 0★★★★−
Dysrhythmia Interpretation 0★★★★−
Dysrhythmia Management 0★★★★−
12 Lead EKG 0★★★★−
National Patient Safety Goals/Core Measures 0★★★★−
Fall Risk Assessment/Prevention 0★★★★−
Pressure Ulcer Risk Assessment/Prevention 0★★★★−
Age Specific/Population-Based Care 0★★★★−
Pain Assessment & Management 0★★★★−
Charge Experience 0★★★★−
Interpretation & Communication of Lab Values 0★★★★−
Specialty Beds 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 ConversionYESNo
BLS
ACLS
PALS
Certification: CAPA or CPAN
Other: Specify
Infant (Birth - 1 year) 0★★★★−
Preschooler (2-5 years) 0★★★★−
Childhood (6-12 years) 0★★★★−
Adolescents (13-21 years) 0★★★★−
Young Adults (22-39 years) 0★★★★−
Adults (40-64 years) 0★★★★−
Older Adults (65-79 years) 0★★★★−
Elderly (80+ years) 0★★★★−
