Home Health Skills Checklist

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Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

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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
Lift / transfer devices	123
Specialty beds	123
Restrictive devices (restraints)	123
End of life care / palliative care	123
Skin / wound assessment & care	123
Diabetic care & education	123
Blood Glucose Monitoring (BGM)	123
General nursing assessment	123
Recognizing failure to thrive across the lifespan	123
Monitoring of vital signs	123
Monitoring of intake / output	123
Monitoring of weight	123
Cardiac / respiratory arrest / CPR adult	123
Cardiac / respiratory arrest / CPR pediatric or infant	123
Documentation of skilled care (written) or computerized	123
Medicare 485 / 486 forms	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Medication reconciliation	123
Anticoagulation therapy	123
Pain assessment & management	123
Infection control (nosocomial / community-acquired)	123
Anti-infective therapy (antibiotics, antivirals, antifungals)	123
Universal precautions	123
Awareness of HCAHPS	123
General Skills - cont. Experience	123
Isolation	123
Minimize risk falls	123
Prevention of pressure ulcers	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 / auscultation of lung sounds	123
Incentive spirometry	123
Principles of chest percussion	123
Establishing an airway	123

THERAPY 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 *

Starting & maintaining peripheral IVs	123
Blood draw: venous	123
Central line care (includes PICC / Groshong / Hickman)	123
Blood draw: central line	123
Care & management of ports	123
Care & management of nonvascular devices (epidural, intrathecal)	123
TPN & lipids	123
Administration of blood and blood products	123
Administration of chemotherapy	123
Monitoring of chemotherapy (does not initiate)	123
Infusion pumps	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 *

Cardiovascular assessment	123
Clinical identification of dysrythmias (AP check for rate & rhythm)	123

CARE OF PATIENTS 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 *

Hypertension	123
Coronary Artery Disease (CAD)	123
Acute MI	123
Post Coronary Artery Bypass Graft (CABG) / valve	123
CHF	123
Aneurysm (thoracic or abdominal)	123
Pre-post surgery	123

MEDICATION ADMINISTRATION / PATIENT TEACHING:

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 *

Antidysrhythmics (i.e., betablockers, calcium channel blockers & cardiac glycosides)	123
Antihypertensives	123
Vasoactive drugs (NTG)	123
Diuretics (i.e., lasix, dyazide)	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 / auscultation of lung sounds	123
Incentive spirometry	123
Principles of chest percussion	123
Establishing an airway	123

RESPIRATORY EXPERIENCE - 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 *

Asthma	123
COPD	123
Pulmonary hypertension	123
Tracheostomy	123
Lung cancer	123
Pulmonary emboli	123

MEDICATION ADMINISTRATION / PATIENT TEACHING:

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 *

Aminophylline	123
Bronchodilators (Bronkosol / Brethine)	123
Expectorants	123
Inhaled medications (proventil / anticholinergics / steroids / mucolytics)	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 *

Assessment of neuro signs	123
Seizure precautions	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 *

Coma	123
Cerebral tumors	123
Seizure activity	123
Spinal cord injury / paralysis (para / quad)	123
TBI (Traumatic Brain Injury)	123
TIA’s	123
Stroke (CVA) hemiparesis	123
Alzheimer’s Disease	123
Meningitis	123
Multiple sclerosis	123
Parkinson’s disease	123
ALS (Amyotrophic Laterial Sclerosis)	123

MEDICATION ADMINISTRATION / PATIENT TEACHING:

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 *

Cortocosteroids	123
Anticonvulsant	123
MAOIs	123
Antidyskinetics	123
Skeletal muscle relaxants	123
Dopamine (blockers & stimulants)	123

GI / 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 *

NG tube	123
Long term feeding tube (Keofeed, Dobhoff)	123
PEG / gastrostomy tube	123
Tube feeding	123
Drainage tubes (surgical & non- surgical)	123
G.I. bleed	123
Colostomy / ileostomy care	123
Ileal conduit	123
G.U. irrigations	123
Suprapubic catheter	123

CARE OF PATIENTS 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 *

Shunts & fistulas	123
Straight catheterization	123
Self catheterization	123
Incontinence	123
Peritoneal dialysis	123
Hemodialysis	123

GYNECOLOGY 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
Self breast exam	123
Mastectomy	123
Hysterectomy	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 replacements (knee / hip / shoulder)	123
Crutch walking	123
Assistive devices	123
Arthroscopy / arthrotomy	123
TENS unit	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 *

Arthritis	123
Amputation	123
Casts	123
Fractures	123

MATERNAL - CHILD CARE 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 & care of complicated pregnancy	123
Breast feeding	123
Homecare of postpartum mother	123
Healthy baby	123

NEWBORN 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 *

Bulb suctioning	123
Cord & circumcision care	123
Phototherapy	123
NG feedings	123

PEDIATRICS:

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 *

Medication calculation for pedi dosing	123
Use of croup tent	123
Oxyhood	123

CARE OF PEDIATRIC 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 *

Asthma	123
Bone marrow transplant	123
Bronco- pulmonary dysplasia	123
Cardiac surgery	123
Cystic fibrosis	123
Epiglottiditis	123
Near drowning	123
Overdose / poison ingestion	123
Post harrington rod insertion	123
Respiratory Distress Syndrome (RDS)	123
Reye’s syndrome	123
Sickle cell disease	123
Spina bifida	123

USE OF EQUIPMENT FOR ALL AGE GROUPS 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 *

Cardiac monitors	123
Wound VAC	123
Apnea monitors	123
O2 administration (NC / mask)	123
Ultrasonic nebulizer	123
Ventilators	123

SOFTWARE PROGRAMS 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 *

MeDecision	123
TILE	123
OASIS	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
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. *