MA Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

Clinical Setting

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Experience in the following clinical service settings:
*

Skilled Nursing Facility	1234
Long term care	1234
Assisted Living	1234
Rehabilitation hospital/LTAC	1234
Behavioral Health	1234
Acute care/hospital	1234
Clinic/Ambulatory	1234
Physician office	1234

Anatomy & Physiology

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Competent in normal structures, pathophysiology, and disease processes of:
*

Cardiovascular system	1234
Respiratory system	1234
Musculoskeletal system	1234
Integumentary system	1234
Nervous system	1234
Gastrointestinal system	1234
Genitourinary system	1234
Reproductive system	1234
Endocrine system	1234
Hepatic/Lymphatic systems	1234

Infection Control

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Implementation and management of:
*

Hand hygiene	1234
Precautions (contact, airborne, droplet)	1234
Prevention and protocols for known infections	1234
Prevention and protocols for MRSA, C.Diff, Sepsis, etc.	1234
Prevention of surgical site infections	1234
Cleaning supplies, equipment, and treatment rooms	1234
Sterilization of instruments	1234
PPE for standard precautions	1234
Biohazard disposal/waste	1234
Sterile technique	1234

Patient Preparation

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Initiate and complete these tasks:
*

Blood pressure	1234
Pulse	1234
Temperature	1234
Oxygen saturation	1234
Height and weight	1234
Recognize normal and abnormal values	1234
Auscultation and palpation during physical examination	1234
Body positioning/draping	1234
Subjective data collection (chief complaint, medical history, family history, etc.)	1234

Procedures

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Initiate, assist, and/or complete these tasks:
*

Eye irrigation	1234
Ear irrigation	1234
Dressing change	1234
Suture/staple removal	1234
Sterile procedures	1234
Skin preparation	1234
Instrument set up	1234

Collection of specimens

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Initiate, assist, and/or complete these tasks:
*

Straight urinary catheterization	1234
Use of incubator	1234
Venipuncture for blood collection	1234
Selection of appropriate colored tubes	1234
Clean catch urine	1234
24-hr urine collection	1234
Fecal specimen	1234
Sputum specimen	1234
Swabs (throat, genital, wound, nasopharyngeal)	1234
Proper labeling	1234
Specimen preservation (refrigeration, etc.)	1234
Use of centrifuge	1234
Use of microscope	1234
Microbiology slides	1234
QA/QC of laboratory and/or diagnostic equipment	1234

Diagnostic testing

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Initiate, assist, and/or complete these tasks:
*

Allergy testing	1234
Holter monitor application	1234
Cardiac stress test	1234
EKG	1234
Blood glucose (capillary) testing	1234
Color-blind testing	1234
Visual acuity testing	1234
Auditory/hearing testing	1234
Pulmonary function testing	1234
TB/PPD skin testing	1234

Pharmacology

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Initiate, calculate, assist, and/or complete these tasks:
*

Rectal suppositories	1234
Use of ampules	1234
Use of powder for reconstitution	1234
Administration of allergy injections	1234
Preparing medications for PO, SQ, SL, ID, IM or topical route	1234
Calculating dosages including metric conversions	1234
IM injections (including Z-track)	1234
SQ injections (including site and needle selection)	1234
Oral and/or sublingual medications	1234
Topical medication application	1234
Eye, ear, nose drop installation	1234
Intradermal	1234
Use of multidose vials	1234
Pre-filled cartridges/needles	1234
Six rights of medication administration	1234
Administration of immunizations	1234
Knowledge of classes of drugs, including indications, side effects, and contraindications	1234

Emergency Management

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Identification, interventions, and responses including: *

Poisoning	1234
CVA (stroke)	1234
Shock	1234
Seizures	1234
Diabetic ketoacidosis	1234
Head injury/concussion	1234
Animal/insect bite	1234
Bleeding	1234
Burns	1234
Cardiac/Respiratory arrest	1234
BLS/CPR protocol	1234
Use of AED	1234
Foreign body obstruction	1234
Choking	1234
Bone fractures	1234
Asthmatic attack	1234
Hyperventilation	1234
Use of crash cart/emergency supplies	1234
Emergency response plans	1234

Patient Education

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Review, discuss and determine patient's knowledge of: *

Anticoagulant monitoring	1234
Cholesterol monitoring	1234
Osteoporosis/bone density	1234
Health maintenance and disease prevention	1234
Home blood glucose monitoring	1234
Patient mobility and assistive devices	1234
Pre-/Post-Op care instructions	1234
Blood pressure monitoring	1234
Various diets (cardiac, diabetic, low salt, low carb, low fat, etc.)	1234
Weight loss remedies	1234
Food allergies	1234
Smoking/tobacco cessation	1234
Substance abuse	1234
Domestic violence/abuse	1234

Front & Back Office

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Identification, management, and implementation of: *

Data entry of post charges, post payments, post adjustments	1234
Petty cash management	1234
Commercial insurance plans	1234
TRICARE	1234
Diagnosis Related Groups (DRGs)	1234
Billing procedures	1234
New patient appointments	1234
Routine vs. emergent appointments	1234
Coordination with outside services (lab, radiology, etc.)	1234
Physician delay/unavailability	1234
Reminders/Call system for appointments	1234
CPT codes	1234
ICD-10 codes	1234
Medicare/Medicaid	1234
Confidentiality of PHI	1234
HIPAA rules and subsequent policies	1234

General & Other

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Experience/competency with the following: *

EMR - McKesson	1234
EMR - Meditech	1234
EMR - Cerner	1234
Glucometer (e.g. Contour, Accu-check, OneTouch, Abbott, etc.)	1234
Pain assessment scales (e.g. 1-10, Wong-Baker, etc.)	1234
Incident/Occurrence reports	1234
EMR - Epic	1234
Pyxis medication dispensing system	1234

Age Specific

Rank each of the following sections on a scale of 1 to 4:
1) No experience
2) Limited experience
3) Experienced
4) Very Experienced

Care of the following age groups: *

Infant (birth to 1 year)	1234
Toddler (ages 1-3 years)	1234
Preschooler (ages 4-5 years)	1234
Childhood (ages 6-12 years)	1234
Adolescent (ages 13-21 years)	1234
Young adults (ages 22-39 years)	1234
Adults (ages 40-64 years)	1234
Older adults (ages 65-79 years)	1234
Elderly (ages 80+ years)	1234

Attestation

ATTESTATION: *

I certify that the information provided 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. *