L&D / Mother / Baby / Post Partum Skills Checklist

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Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

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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 *

Inpatient Acute Care Facility	123
Trauma Center	123
Academic/Teaching Facility	123
Outpatient Care Facility	123
Long term care/Skilled Nursing	123
Clinic/Ambulatory	123
Home Health Setting	123

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 directives	123
Patient / family teaching	123
Discharge planning	123
Lift / transfer devices	123
Specialty beds	123
Restrictive devices (restraints)	123
End of life care / palliative care	123
Wound assessment & care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Bar coding for medication administration	123
Coaching needs: physical / emotional / comfort	123
Assist with sterile speculum exam (effacement, dilation, station, presentation)	123
Vaginal exam (effacement, dilation, station, presentation)	123
Performs sterile speculum exam independently	123
Use of doppler	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Time out protocol	123
Interpretation & communication of lab values	123
Medication administration	123
Labeling (medications & specimens)	123
Medication reconciliation	123
Anticoagulation therapy	123
Monitoring conscious sedation	123
Pain assessment & management	123
Use of PCA (IV)	123
Epidural	123
Infection control	123
Universal precautions	123
Awareness of HCAHPS	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123

CARDIAC MONITORING & EMERGENCY 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 *

Preparation & administration of emergency drugs	123
Infant / neonatal arrest / NRP	123
Adult cardiac arrest / ACLS	123
Obtains 12 lead EKG	123
Interpretation of rhythm strips	123
Use of rapid response teams	123
Pulse oximetry	123
Interpretation of ABG’s	123
O2 (NC / mask / oxyhood)	123
Assist with intubation	123
Suctioning	123

IV 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 *

Start & maintain peripheral IV	123
Start & maintain scalp veins	123
Maintain central lines (CVC / PICC)	123
Administration of blood & blood products	123
TPN/lipids	123
Use of infusion pumps / drips / IV monitoring	123

PATIENT MONITORING 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 *

Assist / monitor anesthesia	123
General anesthesia	123
Regional / spinal / epidural	123

CARE OF PATIENT WITH PRE-EXISTING PROBLEMS:

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 disease	123
Neurological disease	123
Seizure disorder	123
Prior tubal ligation	123
Diabetes mellitus	123
Infectious disease	123
Sickle cell disease	123
RH incompatibilities	123
HIV	123
Substance abuse (subutex, methadone)	123

ANTEPARTUM CARE & PROCEDURES 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 *

Triage of obstetrical patients	123
NST (Non Stress Tests)	123
OCT (Oxytocin Challenge Tests)	123
Reflex checks / edema assessment / clonus	123
Assist with amniocentesis	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 *

Pregnancy induced hypertension	123
Pre-eclampsia / eclampsia	123
Preterm labor	123
VBAC management / trial of labor	123
Placenta previa	123
Abruptio placenta	123
Uterine rupture	123
Multiple gestation	123
Malpresentations (breech / face / brow)	123

MEDICATION & ADMINISTRATION:

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 *

Pitocin (oxytocin)	123
Prostaglandins	123
Cytotec, misoprostol	123
Ritodrine	123
Magnesium sulfate therapy	123
Corticosteroids	123
Insulin drips	123
Terbutaline	123

LABOR ASSESSMENT & PROCEDURES 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 *

Assess & document progression of labor	123
Abdominal / perineal prep	123
Assist with AROM procedure	123
Assess & document fetal status	123
Use of EFM (External Fetal Monitor)	123
Use of IFM (Internal Fetal Monitor)	123
Assist with IUPC placement & calibration	123
Amnioinfusion	123
Assist with vaginal delivery	123
Forceps / vacuum extraction	123
Shoulder dystocia	123
Emergency delivery	123
Hemorrhage / shock	123
Assist with high risk delivery	123
Circulate for c-section	123
Scrub for c-section	123
Assist with fetal scalp blood sampling	123
Fundal assessment / height	123

IMMEDIATE CARE OF BABY IN DELIVERY ROOM 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 assessment / apgar scores	123
Routine neonatal medications	123
Meconium	123
Eye prophylaxis	123
Collect cord sample	123
Heelsticks	123
Radiant warmer / thermoregulation	123
ID / security banding	123

POSTPARTUM 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 *

Fundus / lochia / perineum care	123
Episiotomy / incision care	123
Postop c-section	123
Bladder assessment	123
Foley catheter insertion	123
Baby friendly protocols	123
Couplet care	123
Breast feeding instructions	123

NEWBORN CARE 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 *

Neonatal level II/III (complete NNICU checklist)	123
Newborn nursery	123
Full body assessment	123

ASSIST WITH INSERTION OF & MAINTENANCE OF:

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 *

UAC/UVC	123
Swanz Ganz	123
Obtain specimens from UAC/UVC	123
High Frequency Jet Ventilation (HFJV)	123
Extra Corporeal Membrane Oxygenation (ECMO)	123
Radiant warmers	123
Apnea monitoring	123
Glascow coma scale	123
Assist with lumbar puncture	123
Calculation of pedi dosage	123
Phototherapy	123
Cord & circumsion care	123

CARE OF THE INFANT 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 *

Bowel obstruction	123
Broncho- pulmonary dysplasia	123
Drug addiction / withdrawal	123
CHF	123
Cystic fibrosis	123
Diabetes mellitus	123
HIV	123
Intracranial hemorrhage	123
Low birth weight infants	123
NEC	123
Neuromusclar disease	123
PDA ligation	123
Pneumonia	123
Pulmonary edema	123
RDS	123
Seizure activity	123
Sickle cell disease	123
Spina bifida	123
Systemic infection	123
Tetralogy of fallot	123
Tracheoesophogeal fistula	123
Transposition of great vessels	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. *