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
SETTING
Adult Inpatient: 0★★★★−
ER/Trauma: 0★★★★−
Adult Outpatient: 0★★★★−
Pediatric Inpatient: 0★★★★−
Pediatric Outpatient: 0★★★★−
Procedures
Chest Studies: 0★★★★−
Abdominal Studies: 0★★★★−
Foreign Body/Soft Tissue Studies: 0★★★★−
Specimen Radiography: 0★★★★−
Extremities
Upper: 0★★★★−
Lower: 0★★★★−
Pelvis Obls/Judet Views: 0★★★★−
Pelvis SI Joints: 0★★★★−
Pelvis Sacrum/Coccyx: 0★★★★−
Spine
Cervical Spine-Obls/Flexion/Extension: 0★★★★−
Thoracic Spine-Swimmer’s View: 0★★★★−
Lumbar Spine-Obls/Flexion/Extension: 0★★★★−
Head
Facial Bones: 0★★★★−
Mandible: 0★★★★−
Head (cont.)
Mastoids: 0★★★★−
Orbits: 0★★★★−
Sinus Series: 0★★★★−
TMJ: 0★★★★−
Skull Series: 0★★★★−
Tomography
Renal: 0★★★★−
Spine: 0★★★★−
Fluoroscopy/Contrast Studies
Barium Swallow/Esophagram: 0★★★★−
Modified Barium Swallow/Protocol Swallow: 0★★★★−
Swallow Studies with Videotaping: 0★★★★−
Upper GI Series-Single Contrast: 0★★★★−
Upper GI Series-Air Contrast: 0★★★★−
Small Bowel Follow Through: 0★★★★−
Enema Studies
Barium Enema-Single Contrast: 0★★★★−
Water Soluble Contrast Enema: 0★★★★−
Barium Enema-Air Contrast: 0★★★★−
Lower GI Studies thru Colostomy: 0★★★★−
Cystography
Cystogram: 0★★★★−
Voiding Cystogram: 0★★★★−
Cystography (cont.)
Urethrography: 0★★★★−
Contrast Injection Studies
IVP: 0★★★★−
IVP with Tomograms: 0★★★★−
Myelograms
Cervical Spine: 0★★★★−
Thoracic Spine: 0★★★★−
Lumbar Spine: 0★★★★−
Mobile C-Arm Fluoroscopy
Bronchoscopy with Fluoro Guidance: 0★★★★−
Bedside Line and Tube Placement: 0★★★★−
OR Cases
Sterile Procedures in OR: 0★★★★−
Spine Work: 0★★★★−
Operative Cholangiography: 0★★★★−
Hip Studies: 0★★★★−
Extremity Studies: 0★★★★−
Cystography: 0★★★★−
Retrograde Urography: 0★★★★−
Patient Safety
National Patient Safety Goals: 0★★★★−
Computerized Charting: 0★★★★−
Age Specific Practice Criteria
Newborn/neonate (birth-30 days): 0★★★★−
Infant (30 days-1 year): 0★★★★−
Toddler (1-3 years): 0★★★★−
Preschooler (3-5 years): 0★★★★−
School age children (5-12 years): 0★★★★−
Adolescents (12-18 years): 0★★★★−
Young adults (18-39 years): 0★★★★−
Middle adults (39-64 years): 0★★★★−
Older adults (64+): 0★★★★−
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