Nurse Aide Skills Checklist

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First Name: *

Last Name: *

Mobile Phone Number: *

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GENERAL SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

HIPAA Regulations	123
National Patient Safety Goals	123
Awareness of HCAHPS scores	123
Electronic Medical Record	123
Accurate Patient Identification	123
Proper body mechanics	123
Technique to preserve respect and dignity for patients	123
Introduction of self prior to providing care	123
Preparing thickened liquids	123
Various special diets (diabetic, reduced sodium, pureed, clear liquids, etc.)	123
Post-mortem care	123

CLINICAL TASKS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Vital signs (temp, HR, B/P, Resp)	123
Manual B/P (cuff and stethoscope)	123
Oxygen Saturation (pulse ox)	123
Ambulation with 1-2 assist	123
Ambulation with walker	123
Turn and reposition q2h	123
Fingerstick blood glucose checks	123
Indwelling urinary catheter care (foley)	123
Empty urinary catheter drainage bag	123
General review of skin condition	123
Reporting unusual/concerning information to the primary nurse	123
Empty surgical drains (JP drain)	123
Calculate and record intake/output values	123
Application of oxygen via nasal cannula	123
Proper disposal of soiled linens	123
Incontinence care (urinary and bowel)	123
Proper transfer technique (bed to chair, bed to wheelchair, etc.)	123
Provide privacy during routine care (use of curtains, close door, etc)	123
Use of military time in documentation	123
Perform daily weights	123
Collect specimens (urine, stool, sputum)	123
Administer enema (with nurse supervision)	123
Application and removal of anti-embolic stockings (TED hose)	123
Basic Life Support (chest compressions and rescue breathing)	123
Therapeutic communication techniques for combative patients	123
Ostomy care (with nurse supervision)	123

ACTIVITIES OF DAILY LIVING:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Bed bath	123
Shower	123
Bathtub	123
Perineal care (male and female)	123
Voiding (urinal, bedpan, bedside commode, toilet)	123
Grooming (brush/comb hair, shaving, etc.)	123
Oral care (brush teeth, dentures, etc.)	123
Application of hearing aids and glasses	123
Set up meal tray (opening items, etc.)	123
Assisting with meal times (food, drinks, etc.)	123
Linen changes (occupied and unoccupied beds)	123
Passive range of motion exercises	123
Foot care (as directed by nurse)	123
Hand and nail care (as directed by nurse)	123
Massage (as directed by nurse)	123
Encourage use of adaptive equipment (cane, walker, trapeze bar, etc.)	123
Use on non-skid footwear	123

EQUIPMENT:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Glucometer	123
Mechanical lift	123
Gait belt	123
Call light/bell	123
Electronic BP machine	123
Oxygen saturation monitor (pulse ox)	123
Wrist/ankle restraints	123
Vest restraints (Posey)	123
Nasal cannula	123
Portable O2 tank	123
Wheelchair	123
Reclining chair	123
Continuous passive motion (CPM) machine	123
Various Beds (changing height, using for weight, etc.)	123
Protective devices (skin protectors for heels, elbows, coccyx, etc)	123

INFECTION CONTROL:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Hand hygiene	123
Precautions associated with PPE (transmission, contact, airborne, droplet)	123
Universal Precautions	123
Negative-pressure room	123
Prevention and protocols for HAIs (CAUTI, CLABSI, VAP)	123
Prevention and protocols for MRSA, C.DIFF, Sepsis, etc.	123

PRECAUTIONS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Aspiration	123
Bleeding	123
High fall risk	123
Elopement	123
Suicide	123

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Acute care hospital	123
Long term care	123
Rehabilitation center	123
Home health/private duty	123
Hospice	123

AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Newborn / neonate (birth-30 days)	123
Infant (31 days-1 year)	123
Toddler (ages 2-3 years)	123
Preschool (ages 4-5 years)	123
School age (ages 6-12 years)	123
Adolescent (ages 13-21 years)	123
Young adult (ages 22-39 years)	123
Adult (ages 40-64 years)	123
Older adult (ages 65-79 years)	123
Elderly (ages 80+ years)	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *