Clinic / Urgent Care RN / Primary Care

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

WORK 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 directives	123
Patient/family teaching	123
National Patient Safety Goals	123
Awareness of HCAHPS scores	123
Automated Medication Dispensing System (Pyxis, Omnicell etc)	123
Triage	123
Lift/transfer devices	123
Bar Coding for medication administration	123
Computerized Charting	123
AMA Procedures	123
Electronic Medical Record	123
Accurate Patient identification	123
Interpretation of lab values	123
Labeling of lab specimens	123
Reconciliation	123
Monitoring Conscious Sedation	123
Universal Precautions	123
Isolation	123
Fall Risks	123
Wound care	123
Prevention of pressure ulcers	123
Wound vacs	123

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 IVs	123
Blood Draw: venous	123
Blood Draw: ABG’s	123
Care & Management of Port	123
Care & Management of PICC, Groshong, Hickman	123
TPN Lipids	123

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 *

Obtain 12 lead EKG	123
Interpretation of rhythm strips	123
Treatment of dysrhythmias	123
Interpretation of (cardiac enzymes, Troponin, BNP)	123
Cardiac arrest/CPR/AED	123
Oxygen therapy and delivery	123
Pulse oximetry	123
Use of doppler	123
Defibrillation	123
External Pacer	123

CARDIOVASCULAR ASSESSMENT:

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 *

Auscultation/Irregular Heart Sounds	123
Peripheral Edema	123
PQRST Assessment	123

CARE OF THE 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 *

Aneurysm	123
Angina	123
Angioplasty (pre/post)	123
Arrhythmias	123
Chest Tubes	123
CHF	123
Carotid Endarterectomy	123
Post MI	123
Pre/Post heart catherization	123
Pre/Post cardiac surgery	123

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 *

Anti-arrhythmic	123
Antihypertensives	123
Beta Blocker	123
Diuretics	123
Fibrinolytics	123
Heparin	123
Nitroglycerin	123
Nitrates	123
Morphine	123
Epinephrine, Atropine, Anti-Arrhythmic	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 of abnormal breath sounds (wheezing, stridor, crackles)	123
Abnormal breathing patterns (rapid, labored,)	123
Oral suctioning	123
Nasotracheal suctioning	123
Interpretation of labs/tests (abg’s, pulse oximetry)	123
Tracheostomy care	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 *

Aspiration	123
Asthma/Reactive Airway Disease	123
COPD	123
Pneumonia	123
Pulmonary Embolism	123
Pulmonary Edema	123
Oxygen therapy	123
Manual resuscitation (AMBU bag, MRB)	123
Metered Dose inhaler (MDI)	123
Nebulizers	123
Pneumothorax	123
Inhalation injuries	123
Tuberculosis	123
Emphysema	123
Thyroidectomy	123

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 *

Bronchodilators	123
Diuretics	123
Expectorants	123
Steroids	123

GYNECOLOGY KNOWLEDGE GENERAL SKILLS/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 *

Abnormal uterine bleeding	123
Assist with cultures	123
Doppler/ Fetal Heart Tones	123
Ectopic Pregnancy	123
endometriosis	123
Gyn exam/ pap	123
Pelvic Inflammatory Disease	123
Pregnancy Induced Hypertension	123
Post hysterectomy care	123
Hemorrhage	123
Vaginal bleeding	123
Pelvic Tray	123

NEUROLOGY:

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 *

CVA	123
Altered level of consciousness	123
Glasgow coma scale	123
overdose	123
Traumatic brain injury	123
Delirium tremors	123
Neuromuscular diseases	123
TIA	123
Head Injury	123
Meningitis	123
Spinal Cord Injury	123
Seizure Disorders	123

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 *

Antiepileptics	123
Steroids	123
Spine immobilization	123
Cervical collar	123
Seizure precautions	123
Assist with lumbar puncture	123

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 *

Assessment of bowel sounds/distention	123
Nutritional state	123
Interpretation of labs and electrolyte balance	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 *

Ostomy/colostomy	123
diarrhea	123
Management of PEG tube/tube feeds	123
Constipation/impaction	123
Hepatitis	123
Insertion of Ng tube	123
pancreatitis	123
enemas	123
Nausea/vomiting	123
Paralytic ileus	123

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 *

Activated charcoal	123
Antiemetics	123
Antispasmodics	123
Anticholinergics	123
IV fluids	123
Ipecac	123
laxatives	123

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 insertion/exchange	123
GU irrigation	123
Suprapubic tube maintenance	123
Kidney failure (acute/chronic)	123
Fluid status	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 *

Obstruction	123
Kidney stones	123
Renal trauma	123
Pyelonephritis/UTI	123
Priapism	123
Testicular torsion	123
Urine retention	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 *

Assessment of Range of Motion	123
Assessment of color, warmth, movement, sensation	123
Assist in reduction of dislocation	123
Cast Care	123
Fracture	123
Splints	123
Traction	123
Amputation	123
Ortho Trauma	123
Sprain/Strain	123
Immobilization	123

METABOLIC/ENDOCRINE 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 *

Interpretation of labs	123
Hyperglycemia	123
Hypoglycemia	123
Blood glucose	123
Ketones in urine	123
Diabetic ketoacidosis	123
Hyperosmolar Hyperglycemia	123

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 *

POC Blood glucose monitoring	123
Dextrose	123
Insulin short acting	123
Oral Hypoglycemic medications	123
Insulin Long acting	123

EENT 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 *

Visual Acuity	123
Hearing Acuity	123
Epistaxis	123
Enlarged tonsils	123
Ear irrigation	123
Eye irrigation	123
Nasal foreign body	123
Eye foreign body	123
Ears foreign body	123

PSYCHIATRIC 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 *

Mental Status/Behavior	123
Anxiety/Depression	123
De-escalation techniques for violent behavior	123
ETOH withdrawal	123
Substance abuse over dose	123
Suicide ideation	123
Restraints	123
Antipsychotics	123
Psychiatric Hold	123
Antidepressants	123

INFECTIOUS/COMMUNICABLE DISEASE 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 *

Infectious Disease	123
Isolation Precautions	123
Use of PPE	123
Handwashing	123
Immunosuppression/Neutropenic	123

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 *

Acts of violence	123
Hazardous exposure	123
Disaster management	123
bites	123
Burn care	123
lacerations	123
Assist w/ Sutures/staples	123

WORK SETTING 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 *

Hospital	123
Clinic	123
Urgent care	123

AGE-SPECIFIC 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. *