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★★★★−
Elderly Adults over 79+ years: 0★★★★−
Schedule and manage appointments: 0★★★★−
Organize and maintain patient's medical record: 0★★★★−
File medical records: 0★★★★−
Utilize electronic health records for accurate patient documentation: 0★★★★−
Demostrate telephone techniques: 0★★★★−
ICD-9 Coding: 0★★★★−
ICD-10 Coding: 0★★★★−
CPT Coding: 0★★★★−
Insurance billing: 0★★★★−
Obtain and analyze vital signs: 0★★★★−
Perform comprehensive physical patient assessment: 0★★★★−
Obtain and document patient history: 0★★★★−
Obtain and document patient allergies: 0★★★★−
Recognize abnormal assessment findings and intervene accordingly: 0★★★★−
Prioritize responsibilities for effective safe patient care: 0★★★★−
Utilize two patient identifiers prior to treatments, procedures, and medication administration: 0★★★★−
Utilize multiple screening tools (hearing test, vision test, developmental test): 0★★★★−
Telephone triage procedures: 0★★★★−
Laboratory test interpretation: 0★★★★−
Radiology test interpretation: 0★★★★−
EKG interpretation: 0★★★★−
Develop and maintain nursing care plan: 0★★★★−
Determine time and time intervals: 0★★★★−
Determine start and stop times for time intervals: 0★★★★−
Determine time using military time and analog clock: 0★★★★−
Activate and participate in emergency response plan for emergency situations: 0★★★★−
Perform Basic Life Support, CPR, and Heimlich maneuver: 0★★★★−
Utilize AED for emergency situations: 0★★★★−
Initiate patient referrals to other healthcare agencies: 0★★★★−
Maintain proper body mechanics: 0★★★★−
Understand and follow physicians orders: 0★★★★−
Maintain and apply safety/risk protocols for fall precautions: 0★★★★−
Maintain and apply safety/risk protocols for suicide precautions: 0★★★★−
Perform pain assessment: 0★★★★−
Apply non-pharmacological techniques for pain when appropriate: 0★★★★−
Assess post-surgical patient for complications: 0★★★★−
Perform nursing interventions for end of life care: 0★★★★−
Assess and manage a variety of drains: 0★★★★−
Perform wound/pressure ulcer staging assessment and classification: 0★★★★−
Assess for drug/alcohol dependence and withdrawal: 0★★★★−
Adhere to hand washing guidelines: 0★★★★−
Maintain aseptic technique: 0★★★★−
Maintain Universal Precautions: 0★★★★−
Maintain sterile technique when appropriate: 0★★★★−
Utilize Isolation Precautions when appropriate: 0★★★★−
Utilize Personal Protective Equipment when indicated: 0★★★★−
Disposal of biohazardous materials: 0★★★★−
Maintain clean environment utilizing environmental cleaning procedures: 0★★★★−
Recognition and reporting of suspected abuse/neglect for all age groups: 0★★★★−
Demostrate assertiveness & initiate advocacy for patients: 0★★★★−
Utilize chain of command to ensure safe patient care: 0★★★★−
Abide by Advance Directives: 0★★★★−
Maintain privacy and dignity for each patient: 0★★★★−
Maintain patient confidentiality per HIPAA guidelines: 0★★★★−
Identify and respond to issues of confidentiality: 0★★★★−
Complies with Joint Commission, NPSG, CMS, and other federal/state regulations: 0★★★★−
Report incidents as indicated and follow protocols: 0★★★★−
Report patient conditions as indicated by federal/state regulations: 0★★★★−
I acknowledge and understand the Joint Commission's list of "Do Not Use Abbreviations": YesNo
Communicate accurately and effectively in English, both written and verbal: 0★★★★−
Communicate with patient using age and cultural appropriate methods: 0★★★★−
Respond to and initiate written communication: 0★★★★−
Recognize and respond to verbal communication: 0★★★★−
Collaborate with interdisciplinary teams for care of patient: 0★★★★−
Utilize SBAR communication: 0★★★★−
Utilize problem-solving/decision-making techniques: 0★★★★−
Give and receive reports from other healthcare professionals: 0★★★★−
Delegate effectively to licensed and non-licensed personnel: 0★★★★−
Venipuncture: 0★★★★−
Central line blood draws: 0★★★★−
Capillary puncture: 0★★★★−
Throat specimen collection: 0★★★★−
Urine specimen collection: 0★★★★−
Stool specimen collection: 0★★★★−
Sputum specimen collection: 0★★★★−
Tissue specimen collection: 0★★★★−
Use methods for quality testing: 0★★★★−
Perform urinalysis testing: 0★★★★−
Perform glucometer testing: 0★★★★−
Perform pediatric screenings (PKU): 0★★★★−
Utilize 6 rights of medication administration: 0★★★★−
Utilize dosage calculation formulas: 0★★★★−
Maintain medication and immunization records: 0★★★★−
Provide education to patient regarding medications: 0★★★★−
Obtain history regarding contraindications: 0★★★★−
Obtain history regarding anaphylactic/allergy reactions: 0★★★★−
Assess for therapeutic response, expected outcomes: 0★★★★−
Assess for and manage adverse reactions: 0★★★★−
Waste medications (proper procedures): 0★★★★−
Topical: 0★★★★−
Oral: 0★★★★−
Intradermal injection: 0★★★★−
Intramuscular injection: 0★★★★−
Subcutaneous injection: 0★★★★−
IV push: 0★★★★−
IV infusion: 0★★★★−
Blood transfusion: 0★★★★−
Chemotherapy: 0★★★★−
Insulin: 0★★★★−
Drug overdose treatment: 0★★★★−
Antibiotics: 0★★★★−
Analgesics: 0★★★★−
Narcotics: 0★★★★−
IV Fluids: 0★★★★−
Muscle relaxers: 0★★★★−
Anit-anxiety: 0★★★★−
Sedatives: 0★★★★−
Anticoagulant therapy: 0★★★★−
Determine eligibility to receive vaccine: 0★★★★−
Provide patient education in relation to vaccines: 0★★★★−
PPD placement and reading results: 0★★★★−
Flu vaccine: 0★★★★−
Pneumococcal vaccine: 0★★★★−
Varicella: 0★★★★−
DTaP: 0★★★★−
MMR: 0★★★★−
HepA: 0★★★★−
HepB: 0★★★★−
HPV: 0★★★★−
Rotavirus: 0★★★★−
IPV: 0★★★★−
Hib: 0★★★★−
Meningococcal: 0★★★★−
Identify needs for health maintenance and disease prevention: 0★★★★−
Provide instruction for health maintenance and disease prevention: 0★★★★−
Instruct individuals according to their needs: 0★★★★−
Instruct and demonstrate use and care of patient equipment: 0★★★★−
Explain general office policies: 0★★★★−
Provide education and patient preparation for invasive procedures: 0★★★★−
Obtain patient consent for treatments and procedures: 0★★★★−
Perform time-out procedure: 0★★★★−
Provide Central line/PICC line care: 0★★★★−
Ear lavage: 0★★★★−
Placement and management of peripheral IV: 0★★★★−
Assist with Doppler exams: 0★★★★−
Assist with simple biopsy: 0★★★★−
Assist with I&D: 0★★★★−
Assist with lumbar puncture: 0★★★★−
Assist with wound debridements: 0★★★★−
Assist with Colposcopy: 0★★★★−
Assist with Urodynamic Studies: 0★★★★−
Assist with IUD insertions: 0★★★★−
Assist with bone marrow biopsy: 0★★★★−
Assist with setting of simple bone fractures: 0★★★★−
Assist with suturing: 0★★★★−
Removal of sutures/staples: 0★★★★−
Application of casts/splints: 0★★★★−
Sterile dressing changes: 0★★★★−
Non-sterile dressing changes: 0★★★★−
Oxygen administration: 0★★★★−
Accessing venous ports: 0★★★★−
Measurement and application of anti-embolic stockings: 0★★★★−
Instruct/educate patient to use incentive spirometer: 0★★★★−
Place and manage nasogastric tube: 0★★★★−
Perform oral and nasopharyngeal suctioning: 0★★★★−
Insert and remove indwelling urinary catheter: 0★★★★−
Insert and remove straight urinary catheter: 0★★★★−
General Clinic (more than 5 MDs in practice): 0★★★★−
General Clinic (less than 5 MDs in practice): 0★★★★−
General Internal Medicine: 0★★★★−
Allergy Clinic: 0★★★★−
Endocrinology: 0★★★★−
Gastroenterology: 0★★★★−
Health/Wellness Screening: 0★★★★−
OB/GYN: 0★★★★−
Occupational Health: 0★★★★−
Oncology: 0★★★★−
Orthopedics: 0★★★★−
Pediatrics: 0★★★★−
Rehab Clinic: 0★★★★−
Rheumatology: 0★★★★−
Surgical Practice: 0★★★★−
Utilization Review/Case Management: 0★★★★−
Please list the EMR systems you have used: