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

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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 Facility123
Trauma Center123
Academic/Teaching Facility123
Outpatient Care Facility123
Long term care/Skilled Nursing123
Clinic/Ambulatory123
Home Health Setting123
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
Discharge planning123
Lift / transfer devices123
Specialty beds123
Restrictive devices (restraints)123
End of life care / palliative care123
Wound assessment & care123
Automated Medication Dispensing System, Pyxis, Omnicell, or other123
Bar coding for medication administration123
Coaching needs: physical / emotional / comfort123
Assist with sterile speculum exam (effacement, dilation, station, presentation)123
Vaginal exam (effacement, dilation, station, presentation)123
Performs sterile speculum exam independently123
Use of doppler123
National Patient Safety Goals123
Accurate patient identification123
Effective communication123
Time out protocol123
Interpretation & communication of lab values123
Medication administration123
Labeling (medications & specimens)123
Medication reconciliation123
Anticoagulation therapy123
Monitoring conscious sedation123
Pain assessment & management123
Use of PCA (IV)123
Epidural123
Infection control123
Universal precautions123
Awareness of HCAHPS123
Isolation123
Minimize risk for falls123
Prevention of pressure ulcers123
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 drugs123
Infant / neonatal arrest / NRP123
Adult cardiac arrest / ACLS123
Obtains 12 lead EKG123
Interpretation of rhythm strips123
Use of rapid response teams123
Pulse oximetry123
Interpretation of ABG’s123
O2 (NC / mask / oxyhood)123
Assist with intubation123
Suctioning123
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 IV123
Start & maintain scalp veins123
Maintain central lines (CVC / PICC)123
Administration of blood & blood products123
TPN/lipids123
Use of infusion pumps / drips / IV monitoring123
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 anesthesia123
General anesthesia123
Regional / spinal / epidural123
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 disease123
Neurological disease123
Seizure disorder123
Prior tubal ligation123
Diabetes mellitus123
Infectious disease123
Sickle cell disease123
RH incompatibilities123
HIV123
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 patients123
NST (Non Stress Tests)123
OCT (Oxytocin Challenge Tests)123
Reflex checks / edema assessment / clonus123
Assist with amniocentesis123
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 hypertension123
Pre-eclampsia / eclampsia123
Preterm labor123
VBAC management / trial of labor123
Placenta previa123
Abruptio placenta123
Uterine rupture123
Multiple gestation123
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
Prostaglandins123
Cytotec, misoprostol123
Ritodrine123
Magnesium sulfate therapy123
Corticosteroids123
Insulin drips123
Terbutaline123
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 labor123
Abdominal / perineal prep123
Assist with AROM procedure123
Assess & document fetal status123
Use of EFM (External Fetal Monitor)123
Use of IFM (Internal Fetal Monitor)123
Assist with IUPC placement & calibration123
Amnioinfusion123
Assist with vaginal delivery123
Forceps / vacuum extraction123
Shoulder dystocia123
Emergency delivery123
Hemorrhage / shock123
Assist with high risk delivery123
Circulate for c-section123
Scrub for c-section123
Assist with fetal scalp blood sampling123
Fundal assessment / height123
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 scores123
Routine neonatal medications123
Meconium123
Eye prophylaxis123
Collect cord sample123
Heelsticks123
Radiant warmer / thermoregulation123
ID / security banding123
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 care123
Episiotomy / incision care123
Postop c-section123
Bladder assessment123
Foley catheter insertion123
Baby friendly protocols123
Couplet care123
Breast feeding instructions123
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 nursery123
Full body assessment123
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/UVC123
Swanz Ganz123
Obtain specimens from UAC/UVC123
High Frequency Jet Ventilation (HFJV)123
Extra Corporeal Membrane Oxygenation (ECMO)123
Radiant warmers123
Apnea monitoring123
Glascow coma scale123
Assist with lumbar puncture123
Calculation of pedi dosage123
Phototherapy123
Cord & circumsion care123
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 obstruction123
Broncho- pulmonary dysplasia123
Drug addiction / withdrawal123
CHF123
Cystic fibrosis123
Diabetes mellitus123
HIV123
Intracranial hemorrhage123
Low birth weight infants123
NEC123
Neuromusclar disease123
PDA ligation123
Pneumonia123
Pulmonary edema123
RDS123
Seizure activity123
Sickle cell disease123
Spina bifida123
Systemic infection123
Tetralogy of fallot123
Tracheoesophogeal fistula123
Transposition of great vessels123
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: *