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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 *
Advanced directives123
Patient/family teaching123
Restrictive devices (restraints)123
Lift/transfer devices123
Specialty beds123
End of life care/palliative care123
Automated Medication Dispensing System, Pyxis, Omnicell, or other123
Bar coding for medication administration123
National Patient Safety Goals123
Accurate patient identification123
Effective communication123
Interpretation & communication of lab values123
Medication administration123
Labeling123
Anticoagulation therapy123
Reconciliation123
Monitoring conscious sedation123
Pain assessment & management123
Use of PCA (IV, intrathecal, epidural)123
Infection control123
Universal precautions123
Isolation123
Minimize risk for falls123
Prevention of pressure ulcers123
Wound care123
Wound vacs123
Awareness of HCAHPS123
CARDIAC MONITORING & EMERGENCY 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 *
Obtains 12 lead EKG123
Interpretation of rhythm strips123
Treatment of dysrythmias123
Use of rapid response teams123
Cardiac arrest/CPR123
O2 therapy & delivery123
Pulse oximetry123
Use of doppler123
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 IVs123
Blood draw: venous123
Central line care123
Blood draw: central line123
Care & management of ports123
Care & management of PICC / Groshong / Hickman123
TPN & lipids123
Administration of blood / blood products123
Administration of chemotherapy123
Monitoring chemotherapy (does not initiate)123
OTHER

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 *
Diabetes mellitus123
Blood Glucose Monitoring (BGM)123
Insulin administration123
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 *
Assessment of heart sounds123
Pacemakers - permanent123
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 *
Aneurysm123
Angina123
Angioplasty (pre/post)123
CHF123
Carotid endarterectomy123
Post MI123
Pre/post cardiac cath123
Pre/post cardiac surgery123
USE & ADMINISTRATION OF THE FOLLOWING

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 *
Antiarrhythmic123
Antihypertensives123
Beta blockers123
Diuretics123
Nitrates123
Fibrinolytics / IIb IIIa inhibitors123
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 of breath sounds123
Chest tubes (Emerson / Pleuravac)123
Interpretation of ABG123
Incentive spirometer123
Mechanical ventilation123
Oral suctioning123
Nasotracheal suctioning123
Tracheostomy care123
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 *
COPD123
Pre/post thoracic surgery123
Thyroidectomy123
Pulmonary embolism123
Pulmonary edema123
Pneumothorax123
Pneumonia123
Inhalation injuries123
Tuberculosis123
Emphysema123
Asthma123
USE & ADMINISTRATION OF THE FOLLOWING

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 *
Bronchodilators123
Steroids123
Expectorants123
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 *
Endometriosis123
Gyn exam / pap123
Self breast exam123
Tubal ligation123
Ectopic pregnancy123
Mastectomy / lumpectomy123
Hysterectomy (vaginal or TAHBSO)123
Repair of cystocele / rectocele123
Pelvic inflammatory disease123
Abnormal uterine bleeding123
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 *
Glasgow coma scale123
Seizure precautions123
Assist with lumbar puncture123
Halo traction123
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 *
CVA123
TIA123
Overdose123
Spinal cord injury/trauma123
TBI (Traumatic Brain Injury)123
Pre/post neuro surgery123
Cranial hemorrhage123
Delirium tremors123
Meningitis123
Neuromuscular diseases123
USE & ADMINISTRATION OF THE FOLLOWING

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 *
Antiepileptics123
Corticosteroids123
Steroids123
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 *
NG tube insertion123
Management of small bore feeding tubes (Dobhoff, Keofeed)123
Jejunostomy tube123
PEG tube123
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 *
Pancreatitis123
Hepatitis123
G.I. bleed123
Esophageal bleeding123
Bowel obstruction123
Bowel resection123
Gastric bypass123
Gastric banding123
Whipple procedure123
Transplants123
Colostomy / ileostomy123
Paralytic ileus123
E.R.C.P123
USE & ADMINISTRATION OF THE FOLLOWING

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 *
Anticholinergics (antispas, bentyl or robinul)123
Cathartics123
GENITOURINARY/RENAL 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 *
Catheter insertion123
GU irrigations123
Nephrostomy tube123
Suprapubic tube123
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 *
Hemodialysis123
T.U.R.P.123
Shunts and fistulas123
Nephrectomy123
Peritoneal dialysis123
Renal transplant123
Chronic/acute renal failure123
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 replacement123
Arthroscopic surgery123
Bucks extension123
Fasciotomy123
Fractures123
Spika cast/body cast123
Splints123
CPM123
TENS unit123
Cast care & removal123
Amputation123
Skeletal traction123
Ortho trauma123
Cervical fusion123
Laminectomy123
OTHER 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 *
Care of patient with sepsis123
Oncology123
Chemotherapy123
Radiation therapy123
Radiation implants123
Inpatient hospice123
Suicide precautions123
Burn patients123
Leadership skills (team leader or charge nurse)123
AGE-SPECIFIC CHECKLIST

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 *