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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 Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Advanced directives
Patient / family teaching
Discharge planning
Lift / transfer devices
Specialty beds
Restrictive devices (restraints)
End of life care / palliative care
Wound assessment & care
Automated Medication Dispensing System, Pyxis, Omnicell, or other
Bar coding for medication administration
Coaching needs: physical / emotional / comfort
Assist with sterile speculum exam (effacement, dilation, station, presentation)
Vaginal exam (effacement, dilation, station, presentation)
Performs sterile speculum exam independently
Use of doppler
National Patient Safety Goals
Accurate patient identification
Effective communication
Time out protocol
Interpretation & communication of lab values
Medication administration
Labeling (medications & specimens)
Medication reconciliation
Anticoagulation therapy
Monitoring conscious sedation
Pain assessment & management
Use of PCA (IV)
Epidural
Infection control
Universal precautions
Awareness of HCAHPS
Isolation
Minimize risk for falls
Prevention of pressure ulcers
Cardiac Monitoring & Emergency Care Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Preparation & administration of emergency drugs
Infant / neonatal arrest / NRP
Adult cardiac arrest / ACLS
Obtains 12 lead EKG
Interpretation of rhythm strips
Use of rapid response teams
Pulse oximetry
Interpretation of ABG’s
O2 (NC / mask / oxyhood)
Assist with intubation
Suctioning
IV Therapy Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Start & maintain peripheral IV
Start & maintain scalp veins
Maintain central lines (CVC / PICC)
Administration of blood & blood products
TPN/lipids
Use of infusion pumps / drips / IV monitoring
Patient Monitoring Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Assist / monitor anesthesia
General anesthesia
Regional / spinal / epidural
Care of Patient with Pre-existing Problems
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Cardiac disease
Neurological disease
Seizure disorder
Prior tubal ligation
Diabetes mellitus
Infectious disease
Sickle cell disease
RH incompatibilities
HIV
Substance abuse (subutex, methadone)
Antepartum Care & Procedures Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Triage of obstetrical patients
NST (Non Stress Tests)
OCT (Oxytocin Challenge Tests)
Reflex checks / edema assessment / clonus
Assist with amniocentesis
Care of Patient with:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Pregnancy induced hypertension
Pre-eclampsia / eclampsia
Preterm labor
VBAC management / trial of labor
Placenta previa
Abruptio placenta
Uterine rupture
Multiple gestation
Malpresentations (breech / face / brow)
Medication & Administration
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Pitocin (oxytocin)
Prostaglandins
Cytotec, misoprostol
Ritodrine
Magnesium sulfate therapy
Corticosteroids
Insulin drips
Terbutaline
Labor Assessment & Procedures Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Assess & document progression of labor
Abdominal / perineal prep
Assist with AROM procedure
Assess & document fetal status
Use of EFM (External Fetal Monitor)
Use of IFM (Internal Fetal Monitor)
Assist with IUPC placement & calibration
Amnioinfusion
Assist with vaginal delivery
Forceps / vacuum extraction
Shoulder dystocia
Emergency delivery
Hemorrhage / shock
Assist with high risk delivery
Circulate for c-section
Scrub for c-section
Assist with fetal scalp blood sampling
Fundal assessment / height
Immediate Care of Baby in Delivery Room Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Newborn assessment / apgar scores
Routine neonatal medications
Meconium
Eye prophylaxis
Collect cord sample
Heelsticks
Radiant warmer / thermoregulation
ID / security banding
Postpartum Care Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Fundus / lochia / perineum care
Episiotomy / incision care
Postop c-section
Bladder assessment
Foley catheter insertion
Baby friendly protocols
Couplet care
Breast feeding instructions
Newborn Care General Skills Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Neonatal level II/III (complete NNICU checklist)
Newborn nursery
Full body assessment
Assist with Insertion of & Maintenance of:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
UAC/UVC
Swanz Ganz
Obtain specimens from UAC/UVC
High Frequency Jet Ventilation (HFJV)
Extra Corporeal Membrane Oxygenation (ECMO)
Radiant warmers
Apnea monitoring
Glascow coma scale
Assist with lumbar puncture
Calculation of pedi dosage
Phototherapy
Cord & circumsion care
Care of the Infant with:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Bowel obstruction
Broncho- pulmonary dysplasia
Drug addiction / withdrawal
CHF
Cystic fibrosis
Diabetes mellitus
HIV
Intracranial hemorrhage
Low birth weight infants
NEC
Neuromusclar disease
PDA ligation
Pneumonia
Pulmonary edema
RDS
Seizure activity
Sickle cell disease
Spina bifida
Systemic infection
Tetralogy of fallot
Tracheoesophogeal fistula
Transposition of great vessels
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)
Adolescents (ages 13-21 years)
Young adult (ages 22-39 years)
Adults (ages 40-64 years)
Older adult (ages 65-79 years)
Elderly (ages 80+ years)
ATTESTATION *