Your name
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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.
Acute Coronary Syndrome 0★★★★−
Congestive Heart Failure 0★★★★−
Post Open Heart (12-24 hours) 0★★★★−
Carotid Endarterectomy 0★★★★−
Post Vascular Surgery 0★★★★−
Heart Transplant 0★★★★−
Pacemaker - Temporary/Permanent 0★★★★−
Pacemaker - Epicardial 0★★★★−
Sheath Removal 0★★★★−
Heart Sounds 0★★★★−
Pneumonia 0★★★★−
Respiratory Distress 0★★★★−
COPD 0★★★★−
Breath Sounds 0★★★★−
Post Thoracic Surgery 0★★★★−
Chest Tube Placement & Management 0★★★★−
Trach Management 0★★★★−
Modes of Ventilation (AC/PC/SIMV/CPAP) 0★★★★−
Intubation/Extubation 0★★★★−
External CPAP/BiPAP 0★★★★−
Interpretation of Arterial Blood Gases 0★★★★−
Stroke Scale Assessment 0★★★★−
CVA 0★★★★−
Brain Injury 0★★★★−
Post Craniotomy 0★★★★−
Spinal Cord Injury 0★★★★−
Seizure Disorders 0★★★★−
ETOH/Drug Withdrawal 0★★★★−
GI Bleeding 0★★★★−
GI Surgery 0★★★★−
Liver Failure 0★★★★−
Pancreatitis 0★★★★−
Liver Transplant 0★★★★−
Pancreas Transplant 0★★★★−
Renal Failure 0★★★★−
Renal Surgery 0★★★★−
Renal Transplant 0★★★★−
Arteriovenous Fistula/Shunt 0★★★★−
Nephrostomy Tubes 0★★★★−
Peritoneal Dialysis 0★★★★−
Diabetes - Hypo/Hyperglycemic Crisis 0★★★★−
Pituitary Disorders 0★★★★−
IV Insulin Protocols 0★★★★−
Indwelling Insulin Pumps 0★★★★−
Anti-Arrhythmics 0★★★★−
Anticoagulants (IV, oral, & injection) 0★★★★−
Anti-Hypertensives 0★★★★−
Anti-Psychotics 0★★★★−
Anti-Seizure Medications 0★★★★−
Benzodiazepines 0★★★★−
Procedural Sedation 0★★★★−
Diuretics 0★★★★−
Emergency Medications 0★★★★−
Inhaled Medications 0★★★★−
Insulin 0★★★★−
Titrate Vasoactive Drips 0★★★★−
Manage Vasoactive Drips - No Titration 0★★★★−
Narcotics/Opioid Analgesics (IV, oral, & injection) 0★★★★−
Nitrates (Oral & Topical) 0★★★★−
Non-Opioid Analgesics (IV, Oral, & Injection) 0★★★★−
Reversal Agents 0★★★★−
Steroids (IV, Oral, Inhaled) 0★★★★−
Automated Medication Dispensing (i.e. Pyxis, Omnicell) 0★★★★−
Starting Ivs 0★★★★−
Central Line Blood Draws 0★★★★−
Central Line/Implanted Line Care 0★★★★−
Arterial Line Management 0★★★★−
TPN & Lipids 0★★★★−
Blood Product Administration 0★★★★−
Administration of Chemotherapy 0★★★★−
Dysrhythmia Interpretation 0★★★★−
Dysrhythmia Management 0★★★★−
Obtain 12 Lead EKG 0★★★★−
Interpret 12 Lead EKG 0★★★★−
Cardioversion 0★★★★−
Defibrillation 0★★★★−
Malignant Hyperthermia 0★★★★−
National Patient Safety Goals/Core Measures 0★★★★−
Fall Risk Assessment/Prevention 0★★★★−
Pressure Ulcer Risk Assessment/Prevention 0★★★★−
Restraints/Use of Least Restrictive Device 0★★★★−
Patient/Family Teaching 0★★★★−
Age Specific/Population-Based Care 0★★★★−
Isolation Precautions 0★★★★−
Infection Prevention 0★★★★−
Pain Assessment & Management 0★★★★−
Charge Experience 0★★★★−
Interpretation and 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 Conversion YESNO
BLS
ACLS
PALS
PCCN
CCRN
Critical Care Course
Telemetry Certificate/Course
Other: Specify
