This checklist was electronically signed on (Today’s date)
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.
Proficiency Scale:
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Advanced directives
Awareness of HCAHPS
Patient/family teaching
Discharge planning
UR/medicare review
Lift/transfer devices
Specialty beds
Restrictive devices (restraints)
End of life care/palliative care
Automated Medication Dispensing System, Pyxis, Omnicell, or other
National Patient Safety Goals
Accurate patient identification
Effective communication
Interpretation & communication of lab values
Medication administration
Labeling (medications & specimens)
Medication reconciliation
Anticoagulation therapy
Pain assessment & management
Infection control
Universal precautions
Isolation
Minimize risk for falls
Prevention of pressure ulcers
Assessment of heart sounds
Identification of arrhythmias (rate/rhythm)
Pacemakers/AID’s
Cardiac arrest/CPR
Hypertension
Pre/post MI
CHF
Post cardiac surgery
Fluid & electrolyte imbalances
Medication Administration - Anticoagulants
Medication Administration - Antiarrhythmics
Medication Administration - Beta blockers
Medication Administration - Nitroglycerin
Medication Administration - Diuretics
Assessment/auscultation of lung sounds
Establishing an airway
Chest PT
Incentive spirometry
Supplemental oxygen (cannula, facemask)
Tracheostomy care
Suctioning (tracheostomy & nasotracheal)
Nebulizer use
Care of Patient with: Pneumonia
Care of Patient with: Asthma
Care of Patient with: COPD
Care of Patient with: Emphysema
Use & Administration of: Bronchodilators
Use & Administration of: Expectorants
Use & Administration of: Corticosteroids
Assessment of neuro signs
Seizure precautions
Care of Patient with: TBI (Traumatic Brain Injury: history of)
Care of Patient with: Seizure activity
Care of Patient with: Spinal cord injury
Care of Patient with: Stroke (CVA)
Care of Patient with: Multiple sclerosis
Care of Patient with: Alzheimer’s disease
Care of Patient with: Parkinson’s disease
Care of Patient with: ALS (Amyotrophic Lateral Sclerosis)
Use & Administration of: Antiseizure medications
Use & Administration of: Antiemetics
Use & Administration of: Laxatives
Use & Administration of: Enemas
Use & Administration of: Bowel prep
NG tube (insertion/removal)
Long term feeding tubes (dobhoff/keofeed)
Gastrostomy tube
Tube feedings
Monitoring input/output
Care of Patient with: Colostomy/ileostomy
Care of Patient with: GI bleed
Care of Patient with: Feeding devices/adaptive equipment
Care of Patient with: GT/PEG feedings
Foley catheter insertion/removal
GU irrigations
Nephrostomy tube
Suprapubic catheter
Ileo conduit
Use of bladder scan equipment
Care of Patient with: Shunts and fistulas
Incontinence/bladder training
Chronic renal failure/dialysis
Peritoneal dialysis
Total joint replacement
Arthroscopic surgery
Cast care
Pulse/CMS checks
Suture/staple removal
Prosthesis application
Standard extremity braces
Care of Patient with: Amputation
Care of Patient with: Stump wrapping
Care of Patient with: Laminectomy
Care of Patient with: Assistive devices
Care of Patient with: CPM machines
Start & maintain Ivs
Blood draw: venous
Central line care (PICC)
Blood draw: central line PICC
Care & management of ports
Infusion pumps
Administration of blood/blood products
Wound care/surgical
Wound care/medical
Dressing changes
Skin assessment
Wound vac
Newborn/neonate (birth-30 days)
Infant (31 days-1 year)
Toddler (2-3 years)
School age (ages 6-12 years)
Preschool (ages 4-5 years)
Adolescents (ages 13-21 years)
Young adult (ages 22-39 years)
Adults (ages 40-64 years)
Older adult (ages 65-79 years)
Elderly (ages 80+ years)
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