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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 SKILLS *
Advanced directives123
Patient / family teaching123
Lift / transfer devices123
Specialty beds123
Restrictive devices (restraints)123
End of life care / palliative care123
Skin / wound assessment & care123
Diabetic care & education123
Blood Glucose Monitoring (BGM)123
General nursing assessment123
Recognizing failure to thrive across the lifespan123
Monitoring of vital signs123
Monitoring of intake / output123
Monitoring of weight123
Cardiac / respiratory arrest / CPR adult123
Cardiac / respiratory arrest / CPR pediatric or infant123
Documentation of skilled care (written) or computerized123
Medicare 485 / 486 forms123
National Patient Safety Goals123
Accurate patient identification123
Effective communication123
Interpretation & communication of lab values123
Medication administration123
Medication reconciliation123
Anticoagulation therapy123
Pain assessment & management123
Infection control (nosocomial / community-acquired)123
Anti-infective therapy (antibiotics, antivirals, antifungals)123
Universal precautions123
Awareness of HCAHPS123
General Skills - cont. Experience123
Isolation123
Minimize risk falls123
Prevention of pressure ulcers123
RESPIRATORY EXPERIENCE *
Assessment / auscultation of lung sounds123
Incentive spirometry123
Principles of chest percussion123
Establishing an airway123
THERAPY EXPERIENCE *
Starting & maintaining peripheral IVs123
Blood draw: venous123
Central line care (includes PICC / Groshong / Hickman)123
Blood draw: central line123
Care & management of ports123
Care & management of nonvascular devices (epidural, intrathecal)123
TPN & lipids123
Administration of blood and blood products123
Administration of chemotherapy123
Monitoring of chemotherapy (does not initiate)123
Infusion pumps123
CARDIAC EXPERIENCE *
Cardiovascular assessment123
Clinical identification of dysrythmias (AP check for rate & rhythm)123
CARE OF PATIENT WITH *
Hypertension123
Coronary Artery Disease (CAD)123
Acute MI123
Post Coronary Artery Bypass Graft (CABG) / valve123
CHF123
Aneurysm (thoracic or abdominal)123
Pre-post surgery123
MEDICATION ADMINISTRATION / PATIENT TEACHING *
Antidysrhythmics (i.e., betablockers, calcium channel blockers & cardiac glycosides)123
Antihypertensives123
Vasoactive drugs (NTG)123
Diuretics (i.e., lasix, dyazide)123
RESPIRATORY EXPERIENCE *
Assessment / auscultation of lung sounds123
Incentive spirometry123
Principles of chest percussion123
Establishing an airway123
RESPIRATORY EXPERIENCE - CARE OF PATIENT WITH *
Asthma123
COPD123
Pulmonary hypertension123
Tracheostomy123
Lung cancer123
Pulmonary emboli123
MEDICATION ADMINISTRATION / PATIENT TEACHING *
Aminophylline123
Bronchodilators (Bronkosol / Brethine)123
Expectorants123
Inhaled medications (proventil / anticholinergics / steroids / mucolytics)123
NEUROLOGY EXPERIENCE *
Assessment of neuro signs123
Seizure precautions123
Halo traction123
CARE OF PATIENT WITH *
Coma123
Cerebral tumors123
Seizure activity123
Spinal cord injury / paralysis (para / quad)123
TBI (Traumatic Brain Injury)123
TIA’s123
Stroke (CVA) hemiparesis123
Alzheimer’s Disease123
Meningitis123
Multiple sclerosis123
Parkinson’s disease123
ALS (Amyotrophic Laterial Sclerosis)123
MEDICATION ADMINISTRATION / PATIENT TEACHING *
Cortocosteroids123
Anticonvulsant123
MAOIs123
Antidyskinetics123
Skeletal muscle relaxants123
Dopamine (blockers & stimulants)123
GI / GU EXPERIENCE *
NG tube123
Long term feeding tube (Keofeed, Dobhoff)123
PEG / gastrostomy tube123
Tube feeding123
Drainage tubes (surgical & non- surgical)123
G.I. bleed123
Colostomy / ileostomy care123
Ileal conduit123
G.U. irrigations123
Suprapubic catheter123
CARE OF PATIENT WITH *
Shunts & fistulas123
Straight catheterization123
Self catheterization123
Incontinence123
Peritoneal dialysis123
Hemodialysis123
GYNECOLOGY EXPERIENCE *
Endometriosis123
Self breast exam123
Mastectomy123
Hysterectomy123
ORTHOPEDIC EXPERIENCE *
Total joint replacements (knee / hip / shoulder)123
Crutch walking123
Assistive devices123
Arthroscopy / arthrotomy123
TENS unit123
CARE OF PATIENT WITH *
Arthritis123
Amputation123
Casts123
Fractures123
MATERNAL - CHILD CARE EXPERIENCE *
Assessment & care of complicated pregnancy123
Breast feeding123
Homecare of postpartum mother123
Healthy baby123
NEWBORN CARE *
Bulb suctioning123
Cord & circumcision care123
Phototherapy123
NG feedings123
PEDIATRICS *
Medication calculation for pedi dosing123
Use of croup tent123
Oxyhood123
CARE OF PEDIATRIC PATIENT WITH *
Asthma123
Bone marrow transplant123
Bronco- pulmonary dysplasia123
Cardiac surgery123
Cystic fibrosis123
Epiglottiditis123
Near drowning123
Overdose / poison ingestion123
Post harrington rod insertion123
Respiratory Distress Syndrome (RDS)123
Reye’s syndrome123
Sickle cell disease123
Spina bifida123
USE OF EQUIPMENT FOR ALL AGE GROUPS EXPERIENCE *
Cardiac monitors123
Wound VAC123
Apnea monitors123
O2 administration (NC / mask)123
Ultrasonic nebulizer123
Ventilators123
SOFTWARE PROGRAMS EXPERIENCE *
MeDecision123
TILE123
OASIS123
AGE SPECIFIC COMPETENCIES EXPERIENCE *
Newborn / neonate (birth-30 days)123
Infant (31 days-1 years)123
Toddler (2-3 years)123
Preschool (ages 4-5 years)123
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 (80+ years)123
ATTESTATION *