Occupational Therapy Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

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 *

General acute care	123
Adult/adult ICU	123
Pediatrics/PICU	123
Children’s hospital	123
Hand therapy	123
Home health care	123
Outpatient neuro	123
Outpatient ortho	123
Psychiatric hospital	123
Rehabilitation hospital/inpatient rehabilitation unit	123
Skilled care facility	123
School setting	123
Early intervention	123
Subacute	123

ORTHOPEDICS 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 *

Hand injury	123
Total joint replacement/upper extremities	123
Lower back/spinal surgeries	123
Arthritis programs	123
Soft tissue injuries	123
Knee injuries & total knee replacement	123
Hip fractures & total hip replacement	123
Mobilization techniques	123
Prosthetics/amputations	123

NEUROLOGIC 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 *

Alzheimers/dementia	123
Degenerative diseases of the CNS	123
Multiple sclerosis	123
Parkinson’s disease	123
Spinal cord injury	123
Adaptive equipment	123
Neurodevelopmental testing (NDT)	123
Wheelchair evaluation	123
Stroke acute	123
Stroke rehabilitation	123
Functional splinting	123
Traumatic brain injury	123

PEDIATRIC ASSESSMENTS 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 *

Pediatric Assessments Experience	123
Neurodevelopmental testing	123
Developmental screening	123
Sensory-motor testing	123
Visual perceptual testing	123
Feeding/swallowing/oral motor	123
Seating & positioning assessment (i.e. w/c)	123

OTHER ASSESSMENTS 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 *

Physical capacity evaluation	123
Home assessments/home accessibility	123
Activities of daily living	123
Driving evaluation	123
Cognitive/perception	123
Treatment Approaches Experience	123
ADL	123
Cognitive retraining	123
Community re-entry	123
Energy conservation/work simplification techniques	123
Functional transfer training	123
Home safety	123
Lymphedema management	123
Orthotics/Prosthetics training	123
Patient, family & staff training	123
PNF	123
SI	123
Therapeutic exercises/activities	123
Work hardening	123
Splinting	123
Neurodevelopmental testing (NDT)	123
Incontinence management	123

MODALITIES 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 *

Anodyne	123
Biofeedback	123
Electrical stimulation	123
Feeding techniques	123
Fluidotherapy	123
Oral motor facilities	123
Paraffin bath	123
TENS	123
Therapeutic pool	123
Ultrasound	123

PROSTHETICS/ORTHOTICS 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 *

UE prosthetics	123
Static splints	123
Dynamic splints	123
Serial casting	123

OTHER 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 *

Burn management	123
Cardiac rehabilitation	123
Cognitive retraining	123
Computer skills	123
FIM scoring	123
Geriatrics	123
Group dynamics	123
IEP skills	123
Inservice education	123
Job task analysis	123
Therapeutic media	123

KNOWLEDGE OF PAYMENT SOURCES:

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 *

Medicare	123
Medicaid	123
MDS	123

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 *

Patient/family teaching	123
Patients in isolation	123
Patients in restraints	123
Initial evaluation	123
Lift/transfer devices	123
Specialty beds	123
End of life care/palliative care	123

COMPUTERIZED CHARTING:

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 *

Cerner	123
EPIC	123
McKesson	123
Meditech	123

NATIONAL PATIENT SAFETY GOALS:

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 *

Accurate patient identification	123
Effective communication	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Care of patients in isolation	123
Minimize risk of falls	123
Prevention of pressure ulcers	123

AGE-SPECIFIC COMPETENCIES 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 *

Infant (birth to 1 year)	123
Toddler (ages 1-3 years)	123
Preschooler (ages 3-5 years)	123
Childhood (ages 6-12 years)	123
Adolescents (ages 12-21 years)	123
Young Adults (ages 21-39 years)	123
Adults (ages 40-64 years)	123
Older Adults (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. *