Your Contact Information

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

Hospice Care Settings Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Home care
Inpatient hospital care
Extended care facility
Hospice Care
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Advanced directives
Restrictive devices / restraints
Lift / transfer devices
Specialty beds
Diabetes mellitus
Blood Glucose Monitoring (BGM)
Insulin administration
Pain assessment & management
Administration of narcotics / sedatives (fentanyl, Valium, Ativan, roxinal, morphine)
Use of PCA (IV, intrathecal, epidural)
Handling of narcotics in the home environment
Non-pharmacologic strategies
TENS unit
Stages of grieving
Spiritual care
Death & dying counseling
Patient & family coping skills
Patient / family teaching & resources
Quality of life & ethical decision making
Death pronouncement
After treatment (survivorship)
National Patient Safety Goals
Awareness of HCAHPS
Accurate patient identification
Effective communication
Interpretation & communication of lab values
Medication administration
Medication reconciliation
Automated Medication Dispensing System, Pyxis, Omnicell, or other
Bar coding for medications
Anticoagulation therapy
Infection control
Universal precaution
Isolation
Minimize risk for falls
Prevention of pressure ulcers
Pressure ulcer staging & care
Wound care
IV Skills
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Venipuncture for blood draw
Peripheral IV catheter access, maintain & discontinue
Central Venous Catheter (CVC) maintain & discontinue
Peripherally Inserted Central Catheters (PICC)
Groshong / Broviac / Hickman
Ports
Epidural catheter maintenance
Intrathecal catheter maintenance
Repair of torn / punctured catheters
Declotting occluded ports or catheters
IV Therapy Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Needleless systems
Administration of blood & blood products
Administration of chemotherapy
Monitoring chemotherapy
Administration of TPN / lipids
Assessment Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Cardiovascular assessment
Respiratory assessment
Use of Incentive Spirometry (IS)
Use of oxygen
Application of nasal cannula
Application of face mask
Use of nebulizer
Placement of oral / NT airway
Use of ambu bag
Pulse oximetry
Oral and nasotracheal suctioning
Tracheostomy
Neuro assessment
Seizure precautions
Sleep assessment
Care of Patient with:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Depression
Anxiety
Delirium
Fatigue
Gastrointestinal
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Gastrointestinal assessment (GI)
Nutritional assessment
NG tube insertion, management and discontinue
Small bore feeding tube insertion, management and discontinue
Gastrostomy / PEG tube management
Jejunostomy management
Ostomy care
Care of the patient with:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Constipation
Nausea & vomiting
Genitourinary
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Genitourinary Assessment (GU)
Foley catheter: insert, manage & discontinue
Nephrostomy tube
Suprapubic tube
Shunts & fistulas
Care of Patient with:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Peritoneal dialysis
Age Specific Competencies Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Newborn / neonate (birth-30 days)
Infant (31 days-1 year)
Toddler (ages 2-3 years)
Preschool (ages 4-5 years)
School age (ages 6-12 years)
Adolescent (ages 13-21 years)
Young adult (ages 22-39 years)
Adult (ages 40-64 years)
Older adult (ages 65-79 years)
Elderly (ages 80+ years)
ATTESTATION *