Pediatrics 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 *

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 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 *

Normal growth & development	123
Immunizations	123
Provide safe environment for age specific care	123
Recognize signs of failure to thrive	123
Recognize signs of abuse/neglect	123
Advanced directives	123
Awareness of HCAHPS	123
Patient/family teaching	123
Lift/transfer devices	123
Specialty beds	123
Restrictive devices (restraints)	123
End of life care/pallative care	123
Wound assessment & care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Bar coding for medication administration	123
Diabetic care & education	123
Blood Glucose Monitoring (BGM)	123
Insulin administration	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration (PO,IM,IV,PR)	123
Labeling (medications & specimens)	123
Medication reconciliation	123
Anticoagulation therapy	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

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 (includes Broviac/PICC/Groshong/Hickman)	123
Blood draw: central line	123
Care & management of ports	123
TPN & lipids	123
Administration of blood & blood products	123
Administration of chemotherapy	123
Monitoring chemotherapy (does not initiate)	123

CARDIOVASCULAR 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 assessment	123
Cardiac monitoring & emergency care	123
Obtains 12 lead EKG	123
Basic EKG interpretation	123
Use of rapid response teams	123
Cardiac arrest/CPR	123
Administration of PALS protocols & medications	123
Use of Broslow system	123

CARE OF CHILD 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 *

Cogenital heart defects	123
Congestive heart failure	123
Post cardiac cath	123
Post cardiac surgery	123
Cardiomyopathy	123
Pericarditis	123
Shock	123
Rheumatic fever	123
Heart transplant	123
Bacterial endocarditis	123

MEDICATIONS:

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 *

Antidysrythmics	123
Antihypertensives	123
Cardiac glycoside (digoxin)	123

PULMONARY 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 *

Respiratory assessment	123
Rate & work of breathing	123

EQUIPMENT & PROCEDURES:

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 *

Oral/nasal suctioning	123
Tracheostomy care and suctioning	123
Chest Physiotherapy (CPT)	123
Pulse oximeter	123
Ventilator management	123
O2 (NC/mask/oxyhood)	123
Assist with chest tube insertion & management	123

CARE OF CHILD 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 *

Asthma	123
RSV (Respiratory Syncytial Virus)	123
Bronchopulmonary Dysplasia (BPD)	123
Cystic fibrosis	123
Croup	123
Pneumonia	123
Epiglottitis	123
Tuberculosis	123

MEDICATIONS:

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 *

Alupent	123
Aminophylline (obsolete medication)	123
Ventolin	123
Inhaled corticosteroids	123
Respigam/synergis	123

NEUROLOGICAL 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 neurological assessment	123
Assist with lumbar puncture	123
ICP monitoring	123

CARE OF CHILD 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 *

Battered child syndrome	123
Depression	123
TBI (Traumatic Brain Injury)	123
Encephalitis	123
Meningitis	123
Neuromuscular disease	123
Spinal cord injury	123
Seizures	123
Hydrocephalus	123
VP shunt	123
Epilepsy	123
Near drowning	123

MEDICATIONS:

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 *

Stimulants (Ritalin, Adderall)	123
Steroids (Decadron, Solu-Medrol)	123
Anticonvulsants (Dilantin, phenobarbital)	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 *

Assessment of circulation checks

123

EQUIPMENT & PROCEDURES:

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 *

Devised traction (splints, casts, braces)	123
Pinned traction	123

CARE OF CHILD 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 *

Osteomylitis	123
Fractures	123
Post Harrington rod insertion	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 *

GI assessment	123
Abdominal girth measurement	123

EQUIPMENT & PROCEDURES:

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 *

Feedings	123
Bottle	123
Breast	123
Gavage	123
Gastrostomy	123
Nasojejunal	123
Nasogastric and sump tubes to suction	123
Placement of oro/nasogastric tubes	123
Colostomy/ileostomy care	123

CARE OF CHILD 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 *

Anorexia/bulimia	123
Tracheoesophageal Fistula (TEF)	123
Gastroschisis/omphalocele	123
Necrotizing Enterocolitis (NEC)	123
Crohn’s disease	123
Cleft lip/palate	123
Gastroenteritis	123
Pyloric stenosis	123
Ulcerative colitis	123
GE reflux	123
GI bleeding	123
Intestinal parasites	123
Small bowel transplant	123
Surgical abdomen	123

RENAL/GU 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 fluid balance

123

EQUIPMENT & PROCEDURES:

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 *

Assist with suprapubic tap	123
Peritoneal dialysis	123
Insertion & care of Foley catheter	123

CARE OF CHILD 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 *

Glomerular nephritits	123
Ilial conduit ureteral	123
Nephrotic syndrome	123
Wilm’s tumor	123
UTI	123
Hemolytic uremic syndrome	123
Kidney transplant	123

ENDOCRINE SYSTEM EXPERIENCE - CARE OF CHILD 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 *

Onset diabetes	123
Diabetic ketoacidosis	123
Adrenal disorders	123
Cushing’s syndrome	123
Pituitary disorders	123
Pancreas transplant	123
Thyroid malfunction	123

MEDICATIONS:

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 *

Insulin administration	123
Insulin pumps	123
Thyroid	123
Growth hormone	123

HEMATOLOGY/ONCOLOGY 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 *

Assist with bone marrow aspiration

123

CARE OF CHILD 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 *

Anemia	123
Bone marrow transplant	123
Leukemia	123
Sickle cell disease	123
Hemophilia	123
Malignant tumors	123
Spleen trauma/spleenectomy	123
Neutropenic fever	123
Sepsis	123
Hodgkin’s	123

INFECTIOUS DISEASES EXPERIENCE - CARE OF CHILD 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 *

Common childhood communicable diseases	123
HIV/CMV/AIDS	123
Hepatitis	123
Kawasaki disease	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 *

Newborn/neonate (birth-30 days)	123
Infants (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

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. *