Psych / Behavioral Health Skills Checklist

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Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

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TREATMENT SETTINGS 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 *

Inpatient hospital psychiatric unit	123
Inpatient acute psychiatric facility	123
Chronic psychiatric facility	123
Outpatient clinic/community setting	123
Forensic unit (prison)	123
Eating disorder unit	123
Substance abuse/rehab unit	123
Locked unit/ward	123

LEGAL/ETHICAL 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 *

Advanced directives	123
Legal right’s of the mentally ill	123
Informed consent	123
Right to refuse treatment	123
Voluntary commitment	123
Involuntary commitment	123
Restrictive devices (restraints)	123
Use of seclusion	123
Terrasoff “duty to warn”	123

EMERGENCY CARE 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 *

Use of rapid response teams	123
Cardiac arrest/CPR	123
Airway management	123
Oxygen therapy	123
Oral/nasotracheal suctioning	123
Pulse oximetry	123
IV therapy	123
Start & maintaining peripheral IVs	123
Blood draw: venous	123
Infusion pumps	123

SKILLED NURSING CARE 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 *

Assessment of circulation/peripheral pulses	123
Blood Glucose Monitoring (BGM)	123
Foley catheter insertion/maintenance	123
NG tube insertion/maintenance	123
Wound care/dressing changes	123
Administration of blood/blood products	123
Management of fluid/electrolyte balance	123
Seizure precautions	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Awareness of HCAHPS	123
Bar coding for medication administration	123
Labeling (medications & specimens)	123
Medication reconciliation	123
Anticoagulation therapy	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123

CLINICAL ASSESSMENT TOOLS EXPERIENCE - INTELLIGENCE ASSESSMENT:

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 *

Wechsler Intelligence Scale (WAIS)	123
Wechsler Intelligence Scale for Children	123

PSYCHOLOGICAL TESTING:

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 *

Minnesota Multiphasic Personality Inventory (MMPI)	123
Beck Depression Inventory (BDI)	123
Thematic Apperception Test (TAT)	123
Child’s Apperception Test (CAT)	123
Informal cognitive status assessment	123
Mental status assessment	123
Gestalt test	123
Stanford-Binet test	123

COMMUNICATION TECHNIQUES 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 *

Active listening	123
Restatement/reflection	123
Clarification	123
Focusing	123
Confronting	123
Summarizing	123

THERAPEUTIC INTERVENTIONS 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 *

Limit setting	123
Positive reinforcement	123
Reality orientation	123
Questioning	123

PSYCHIATRIC DISORDERS EXPERIENCE - MOOD DISORDERS

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 *

Major depression	123
Dysthymia	123
Bipolar disorder (manic-depressive illness)	123
Type I	123
Type II	123

ANXIETY DISORDERS:

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 *

GAD - Generalized Anxiety Disorder	123
Panic	123
Post Traumatic Stress Disorder	123
Obsessive-compulsive	123
Phobias	123

PSYCHOTIC DISORDERS:

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 *

Schizophrenia	123
Schizoaffective disorder	123
Schizophreniform disorder	123

PERSONALITY DISORDERS:

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 *

Antisocial	123
Passive/aggressive	123
Paranoia	123
Borderline	123
Schizotypal personality disorder	123

CONGENITAL DISORDERS:

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 *

Mental retardation	123
Down’s syndrome	123
Cystic fibrosis	123
Cerebral palsy	123
Spina bifida	123

DEGENERATIVE DISORDERS:

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 *

Alzheimer’s disease	123
Parkinson’s disease	123
Huntington’s chorea	123

EATING DISORDERS:

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 *

Anorexia nervosa	123
Bulimia nervosa	123
Pica	123

CRISIS MANAGEMENT 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 *

Homicide	123
Suicide/suicide precautions	123
Rape	123
Violence/family & individuals	123

SUBSTANCE USE / ABUSE 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 *

Withdrawal syndrome	123
Alcohol or ETOH	123
CIWA scale	123
Delirium tremens (DTs)	123
Wernicke-Korsakoff	123

DRUG USE/ABUSE:

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 *

Hallucinogenics	123
Opiates	123
Heroin	123
Prescription	123
Stimulants (amphetamines/cocaine/MDMA)	123
Benzodiazepine	123
Drug withdrawal/detoxification	123
COWS scale for opiate withdrawal symptom assessment	123

SEXUALITY DYSFUNCTION EXPERIENCE - GENDER IDENTITY DISORDERS:

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 *

Paraphilias	123
Psychosexual dysfunctions	123

CHILD/ADOLESCENT DYSFUNCTION 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 *

Conduct disorder	123
Separation anxiety disorders	123
ADHD (Attention Deficit Hyperactivity Disorder)	123
ADD (Attention Deficit Disorder)	123

ELIMINATION DISORDERS:

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 *

Encopresis	123
Enuresis	123

PERVASIVE DEVELOPMENTAL DISORDERS:

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 *

Autism	123
Asperger’s syndrome	123
Rett syndrome	123
Self destructiveness	123
Suicidal behavior	123
Runaway behavior	123
Substance abuse	123
Delinquent behavior	123
Neglect/lack of parental involvement	123
Physical/sexual abuse	123
Care of the patient with delusions	123
Care of the patient with hallucinations	123

THERAPEUTIC APPROACHES 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 *

Psychotherapy	123
Behavior therapy	123
Milieu management	123
Relationship/family therapy	123
Electroconvulsive Therapy (ECT)	123
Crisis counseling	123
Behavior modification	123
Group therapy	123

MEDICATIONS 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 *

Analgesics/narcotics (MS, Dilaudid, Demerol, fentanyl, methadone)	123
Antidepressants (TCA, MAOIs, SSRIs)	123
Antiolytics (Valium, Ativan, Xanax)	123
Antiparkinson (levodopa, Sinemet)	123
Antipsychotic (Thorazine, Haldol, zyrexa, Seroquel)	123
Mood stabilizer (lithium, Depakote, Tegretol)	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	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 *

School age (ages 6-12 years)	123
Adolescents (ages 13-21 years)	123
Young adult (ages 22-39 years)	123
Adults (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. *