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.
Advanced directives 0★★★★−
Awareness of HCAHPS 0★★★★−
Patient/family teaching 0★★★★−
Discharge planning 0★★★★−
UR/medicare review 0★★★★−
Lift/transfer devices 0★★★★−
Specialty beds 0★★★★−
Restrictive devices (restraints) 0★★★★−
End of life care/palliative care 0★★★★−
Automated Medication Dispensing System, Pyxis, Omnicell, or other 0★★★★−
National Patient Safety Goals 0★★★★−
Accurate patient identification 0★★★★−
Effective communication 0★★★★−
Awareness of patient rights 0★★★★−
Interpretation & communication of lab values 0★★★★−
Medication administration 0★★★★−
Labeling (medications & specimens) 0★★★★−
Medication reconciliation 0★★★★−
Anticoagulation therapy 0★★★★−
Pain assessment & management 0★★★★−
Infection control 0★★★★−
Universal precautions 0★★★★−
Isolation 0★★★★−
Minimize risk for falls 0★★★★−
Prevention of pressure ulcers 0★★★★−
Assessment of heart sounds 0★★★★−
Identification of arrhythmias (rate/rhythm) 0★★★★−
Pacemakers/AID’s 0★★★★−
Cardiac arrest/CPR 0★★★★−
Hypertension 0★★★★−
Pre/post MI 0★★★★−
CHF 0★★★★−
Post cardiac surgery 0★★★★−
Fluid & electrolyte imbalances 0★★★★−
Anticoagulants 0★★★★−
Antiarrhythmics 0★★★★−
Beta blockers 0★★★★−
Nitroglycerin 0★★★★−
Diuretics 0★★★★−
Assessment/auscultation of lung sounds 0★★★★−
Establishing an airway 0★★★★−
Chest PT 0★★★★−
Incentive spirometry 0★★★★−
Supplemental oxygen (cannula, facemask) 0★★★★−
Tracheostomy care 0★★★★−
Suctioning (tracheostomy & nasotracheal) 0★★★★−
Nebulizer use 0★★★★−
Pneumonia 0★★★★−
Asthma 0★★★★−
COPD 0★★★★−
Emphysema 0★★★★−
Bronchodilators 0★★★★−
Expectorants 0★★★★−
Corticosteroids 0★★★★−
Assessment of neuro signs 0★★★★−
Seizure precautions 0★★★★−
TBI (Traumatic Brain Injury: history of) 0★★★★−
Seizure activity 0★★★★−
Spinal cord injury 0★★★★−
Stroke (CVA) 0★★★★−
Multiple sclerosis 0★★★★−
Alzheimer’s disease 0★★★★−
Parkinson’s disease 0★★★★−
ALS (Amyotrophic Lateral Sclerosis) 0★★★★−
Antiseizure medications 0★★★★−
Antiemetics 0★★★★−
Laxatives 0★★★★−
Enemas 0★★★★−
Bowel prep 0★★★★−
NG tube (insertion/removal) 0★★★★−
Long term feeding tubes (dobhoff/keofeed) 0★★★★−
Gastrostomy tube 0★★★★−
Tube feedings 0★★★★−
Monitoring input/output 0★★★★−
Colostomy/ileostomy 0★★★★−
GI bleed 0★★★★−
Feeding devices/adaptive equipment 0★★★★−
Dietary restrictions 0★★★★−
GT/PEG feedings 0★★★★−
Foley catheter insertion/removal 0★★★★−
GU irrigations 0★★★★−
Nephrostomy tube 0★★★★−
Suprapubic catheter 0★★★★−
Ileo conduit 0★★★★−
Use of bladder scan equipment 0★★★★−
Shunts and fistulas 0★★★★−
Straight catheterizations 0★★★★−
Incontinence/bladder training 0★★★★−
Chronic renal failure/dialysis 0★★★★−
Peritoneal dialysis 0★★★★−
Total joint replacement 0★★★★−
Arthroscopic surgery 0★★★★−
Cast care 0★★★★−
Pulse/CMS checks 0★★★★−
Suture/staple removal 0★★★★−
Prosthesis application 0★★★★−
Standard extremity braces 0★★★★−
Amputation 0★★★★−
Stump wrapping 0★★★★−
Laminectomy 0★★★★−
Assistive devices 0★★★★−
CPM machines 0★★★★−
Start & maintain Ivs 0★★★★−
Blood draw: venous 0★★★★−
Central line care (PICC) 0★★★★−
Blood draw: central line PICC 0★★★★−
Care & management of ports 0★★★★−
Infusion pumps 0★★★★−
Administration of blood/blood products 0★★★★−
Wound care/surgical 0★★★★−
Wound care/medical 0★★★★−
Dressing changes 0★★★★−
Skin assessment 0★★★★−
Wound vac 0★★★★−
Newborn/neonate (birth-30 days) 0★★★★−
Infant (31 days-1 year) 0★★★★−
Toddler (2-3 years) 0★★★★−
Preschool (ages 4-5 years) 0★★★★−
School age (ages 6-12 years) 0★★★★−
Adolescents (ages 13-21 years) 0★★★★−
Young adult (ages 22-39 years) 0★★★★−
Adults (ages 40-64 years) 0★★★★−
Older adult (ages 65-79 years) 0★★★★−
Elderly (ages 80+ years) 0★★★★−
