Medical Surgical/Telemetry 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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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 *

Inpatient Acute Care Facility	123
Trauma Center	123
Academic/Teaching Facility	123
Outpatient Care Facility	123
Long term care/Skilled Nursing	123
Clinic/Ambulatory	123
Home Health Setting	123

GENERAL SKILLS:

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
Patient/family teaching	123
Restrictive devices (restraints)	123
Lift/transfer devices	123
Specialty beds	123
End of life care/palliative care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Bar coding for medication administration	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Labeling	123
Anticoagulation therapy	123
Reconciliation	123
Monitoring conscious sedation	123
Pain assessment & management	123
Use of PCA (IV, intrathecal, epidural)	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123
Wound care	123
Wound vacs	123
Awareness of HCAHPS	123

CARDIAC MONITORING & EMERGENCY CARE:

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 *

Obtains 12 lead EKG	123
Interpretation of rhythm strips	123
Treatment of dysrhythmias	123
Use of rapid response teams	123
Cardiac arrest/CPR	123
O2 therapy & delivery	123
Pulse oximetry	123
Use of doppler	123
Automatic/manual blood pressure checks	123

IV THERAPY:

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 *

Starting & maintaining peripheral IVs	123
Blood draw: venous	123
Central line care	123
Blood draw: central line	123
Care & management of ports	123
Care & management of PICC / Groshong / Hickman	123
TPN & lipids	123
Administration of blood / blood products	123
Administration of chemotherapy	123
Monitoring chemotherapy (does not initiate)	123
Management of IV Pumps ( Alaris , Baxter,)	123
Management of elastomeric infusion	123
Management of intrathecal pumps	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 *

Diabetes mellitus	123
Blood Glucose Monitoring (BGM)	123
Insulin administration	123
Sepsis	123
External and temporary pacemakers	123
Management of permanent pacemaker/AICD	123

CARDIAC 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 heart sounds	123
Pacemakers – permanent	123

CARE OF PATIENT WITH:

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 *

Aneurysm	123
Angina	123
Acute MI	123
Angioplasty (pre/post)	123
CHF	123
Carotid endarterectomy	123
Post MI	123
Pre/post cardiac cath	123
Pre/post cardiac surgery (CABG & valves)	123
Pre/post vascular surgery (abdominal or thoracic AA, fem-pop, carotid)	123
Cardiogenic shock	123

USE & ADMINISTRATION OF THE FOLLOWING:

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 *

Antiarrhythmic	123
Antihypertensives	123
Beta blockers	123
Diuretics	123
Nitrates	123
Fibrinolytics / IIb IIIa inhibitors	123
Preparation & administration of emergency (ACLS) meds	123
Antilipemic’s (Statins)	123
Inotropic’s (i.e. digoxin, dopamine. epinephrine)	123

RESPIRATORY 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 breath sounds	123
Airway management/suctioning (ETT, oral,trach)	123
Chest tubes (Emerson / Pleuravac)	123
Interpretation of ABG	123
Incentive spirometer	123
Mechanical ventilation	123
Ambu Bag	123
Nasal Canula	123
Non-rebreather	123
Bronchoscopy	123
Venti Mask	123
Oral suctioning	123
Nasotracheal suctioning	123
Tracheostomy care	123
Heimlich Valve	123

CARE OF PATIENT WITH:

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 *

COPD	123
Tracheostomy	123
Thyroidectomy	123
Pulmonary embolism	123
Pulmonary edema	123
Pneumothorax	123
Pneumonia	123
Inhalation injuries	123
Tuberculosis	123
Emphysema	123
Asthma	123
Thoracentesis/paracentesis	123
Lung Transplant	123

USE & ADMINISTRATION OF THE FOLLOWING:

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 *

Bronchodilators	123
Steroids	123
Expectorants & Antitussives	123
Antihistamines	123
Use of nebulizer treatments	123

GYNECOLOGY/GYN MALIGNANCIES 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 *

Endometriosis	123
Gyn exam / pap	123
Self-breast exam	123
Tubal ligation	123
Ectopic pregnancy	123
Mastectomy / lumpectomy	123
Hysterectomy (vaginal or TAHBSO)	123
Repair of cystocele / rectocele	123
Pelvic inflammatory disease	123
Abnormal uterine bleeding	123
Management of D&C	123

EXPERIENCE WITH:

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 *

Adenosine administration	123
Insertion	123
& management of arterial line	123
Chest tube insertion & management	123
Femoral hemostasis devices (femStop/vasoseal)	123
Ventilator management	123
Interpretation weaning parameters	123

DRUG DOSE CALCULATION FOR:

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 *

Non-titrated IV vasoactive agents (Dobutrex/ dopamine)	123
Nitrates (IV nitroglycerine)	123
Platelet inhibitors (reopro)	123
Fibrinolytics/IIb IIIa inhibitors	123
Anti-arrhythmic agents (amiodarone/ Cardizem/lidocaine)	123
Patient Monitoring (Pre/Post Procedure)	123
Cardioversion	123
TEE	123
Cardiac catheterization	123
Bronchoscopy	123
EGD	123
PEG placement	123

NEUROLOGY 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 *

Glasgow coma scale	123
Seizure precautions	123
Assist with lumbar puncture	123
Halo traction	123
Comprehensive neuro assessment	123

CARE OF PATIENT WITH:

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 *

CVA/TIA	123
Aspiration precautions	123
Overdose/DT’s	123
Spinal cord injury/trauma	123
TBI (Traumatic Brain Injury)	123
Pre/post neuro surgery	123
Cranial hemorrhage	123
Delirium tremors	123
Meningitis	123
Neuromuscular diseases	123
Degenerative neurological disorders	123
CMS Infection	123
Metastatic Tumor/ tumor resection	123
Encephalitis	123
Alzheimer’s	123
Laminectomy	123
Traumatic Brain Injury	123

USE & ADMINISTRATION OF THE FOLLOWING:

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 *

Antiepileptics	123
Corticosteroids	123
Steroids	123
Anticonvulsants (Dilantin/Neurontin/phenobarbital)	123
Anti-depressants	123
Anti-Parkinson (Cogentin/levodopa/Sinemet)	123

GASTROINTESTINAL 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 *

NG tube insertion	123
Management of small-bore feeding tubes (Dobhoff, Keofeed)	123
Jejunostomy tube	123
PEG tube	123
Management of post-surgery drains	123

CARE OF PATIENT WITH:

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 *

Pancreatitis	123
Hepatitis	123
G.I. bleed	123
Esophageal bleeding	123
Bowel obstruction	123
Bowel resection	123
Gastric bypass	123
Gastric banding	123
Whipple procedure	123
Transplants	123
Colostomy / ileostomy	123
Paralytic ileus	123
E.R.C.P.	123
Peritonitis	123
IBD(Crohn’s/Ulcerative Colitis	123
Electrolyte imbalance	123
Pancreatic cancer	123
Liver failure/cancer	123

USE & ADMINISTRATION OF THE FOLLOWING:

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 *

Anticholinergics (antispam, Bentyl or Robinul)	123
Antiemetics	123
Antacids	123
Digestive enzymes	123
Cathartics	123

GENITOURINARY/RENAL 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 *

Catheter insertion	123
GU irrigations	123
Nephrostomy tube	123
Suprapubic tube	123
Fluid & electrolyte disturbance	123

CARE OF PATIENT WITH:

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 *

Hemodialysis	123
T.U.R.P.	123
Shunts and fistulas	123
Nephrectomy	123
Peritoneal dialysis	123
Renal transplant	123
Chronic/acute renal failure	123
UTI	123
BPH	123
Prostate cancer	123
Ileoconduit	123

ORTHOPEDIC 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 *

Total joint replacement	123
Arthroscopic surgery	123
Bucks extension	123
Fasciotomy	123
Fractures	123
Spika cast/body cast	123
Splints	123
CPM	123
TENS unit	123
Cast care & removal	123
Amputation	123
Skeletal traction	123
Ortho trauma	123
Cervical fusion	123
Laminectomy	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 *

Care of patient with sepsis	123
Oncology	123
Chemotherapy	123
Radiation therapy	123
Radiation implants	123
Inpatient hospice	123
Suicide precautions	123
Burn patients	123
Leadership skills (team leader or charge nurse)	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. *