Physical Therapy Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

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 *

Adult/adult ICU	123
Children’s hospital	123
General acute care	123
Home health care	123
Outpatient neuro	123
Outpatient ortho	123
Pediatrics/PICU	123
Psychiatric hospital	123
Rehabilitation hospital	123
School setting	123
Early intervention	123
Skilled care facility	123
Subacute	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
Venous blood draw	123

ORTHOPEDICS 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 *

Upper extremities	123
Arthritis programs	123
Back syndrome	123
Cervical injuries	123
Chronic fatigue syndrome	123
Fibromyalgia	123
Halo traction	123
Hand injury	123
Hip fracture	123
Kyphoplasty	123
Manual therapy	123
Mobilization techniques	123
Pelvic fracture	123
Postpolio syndrome	123
Shoulder injuries	123
TMJ dysfunction	123
Total hip/total knee	123
Total joint replacement	123
Total shoulder/CPM	123

NEUROLOGIC 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 *

ALS	123
Brain tumors	123
Cerebral palsy	123
Multiple sclerosis	123
Muscular dystrophy	123
Polio/post polio syndrome	123
Spinal cord injury	123
Adaptive equipment	123
Functional splinting	123
Neurodevelopmental testing (NDT)	123
Head trauma	123
Glasgow coma scale	123
Stroke rehabilitation	123
Wheelchair prescription	123

PEDIATRICS 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 *

Activities of daily living	123
Adaptive	123
Developmental disability	123
Equipment assessment	123
Individualized education programs	123
Neurodevelopmental testing (NDT)	123
Orthotics	123
Sequencing testing	123
Sports Medicine Experience	123
Biodex	123
Bracing/joint	123
Cybex	123
Immobilization	123
Lido	123
Medical expenses (Norwegian)	123
Nautilus/eagle	123
Orthotron/kinetron	123
Stabilization techniques	123
Swiss ball	123
Taping/strapping	123
Prosthetics/Orthotics Experience	123
Dynamic splints	123
LE prosthetics	123
Protonics	123
Removeable rigid dressings	123
Serial casting	123
Static splints	123
UE prosthetics	123

MODALITIES 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 *

Anodyne	123
Biofeedback	123
Edema massage	123
Fluidotherapy	123
Iontophoresis	123
JOBST compression pump	123
Muscle stimulation	123
Paraffin bath	123
Phonophoresis	123
TENS	123
Therapeutic pool	123
Ultrasound	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 *

Burn management	123
Cardiac rehabilitation	123
Chest physical therapy	123
DME ordering	123
FIM scoring	123
Job task analysis	123
Lymphedema management	123
OASIS assessment for home care	123
Obstetrics in physical therapy	123
Tone management/spasticity	123
Wheelchair ordering for SCI patients	123
Work capacity evaluation	123
Work hardening	123
Wound care	123

KNOWLEDGE OF PAYMENT SOURCES:

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 *

Medicare	123
Medicaid	123
MDS	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 *

Patient/family teaching	123
Patients in isolation	123
Patients in restraints	123
Initial evaluation	123
Lift/transfer devices	123
Specialty beds	123
End of life care/palliative care	123
Computerized Charting	123
Cerner	123
EPIC	123
McKesson	123
Meditech	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Care of patients in isolation	123
Minimize risk of falls	123
Prevention of pressure ulcers	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 *

Infant (birth to 1 year)	123
Toddler (ages 1-3 years)	123
Preschooler (ages 3-5 years)	123
Childhood (ages 6-12 years)	123
Adolescents (ages 12-21 years)	123
Young Adults (ages 21-39 years)	123
Adults (ages 40-64 years)	123
Older Adults (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. *