Corrections Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

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
Cultural diversity	123
Patient teaching	123
Restrictive devices (restraints)	123
Ambulatory cuffs	123
End of life care/palliative care	123
Correctional admission & discharge	123
Correctional alarm systems	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Diabetes mellitus	123
Blood Glucose Monitoring (BGM)	123
Insulin administration	123
National Patient Safety Goals	123
Accurate patient/inmate identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Labeling: obtain lab specimens	123
Anticoagulation therapy	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Isolation	123
Assist with treatment procedures	123
Wound care	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

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 *

Cardiac monitors	123
Interpretation of rhythm strips	123
Obtains 12 lead EKG	123
Treatment of dysrythmias	123
Cardiac arrest/CPR	123
O2 therapy & delivery	123
Pulse oximetry	123
Use of doppler	123
Assessment of heart sounds	123
Vascular assessment	123
Awareness of HCAHPS	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 *

Angina	123
CHF	123
Post MI	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 breath sounds	123
Establishing an airway	123
Ambuing techniques	123
Suctioning	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 *

COPD	123
Pneumocystis	123
Pneumonia	123
Emphysema	123
Asthma	123
Tuberculosis	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
Steroids	123
Expectorants	123

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 *

Gyn exam/pap	123
Self breast exam	123
Ectopic pregnancy	123
Pelvic inflammatory disease	123
Endometriosis	123

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 *

Neurological assessment	123
Glasgow coma scale	123
Seizure precautions	123
Assist with lumbar puncture	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 *

Post CVA	123
TIA	123
Seizure activity	123
Head & spinal cord injury/trauma	123
Cranial hemorrhage	123
Delirium tremors	123
Neuromuscular diseases	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

PSYCHIATRIC DISORDERS 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 *

Psych assessment	123
Suicide risk assessment	123
Suicide precautions	123
Major depression	123
Bipolar disorder (manic-depressive illness)	123
Anxiety disorders	123
Post Traumatic Stress Disorder (PTSD)	123
Psychotic disorders	123
Schizophrenia	123
Personality disorders	123
Antisocial	123
Passive / aggressive	123
Paranoia	123
Schizotypal personality disorder	123
Eating disorders	123
Anorexia nervosa	123
Bulemia nervosa	123
Pica	123

CRISIS MANAGEMENT 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 *

Homicide	123
Suicide	123
Rape	123
Violent individual	123

SUBSTANCE USE/ABUSE 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 *

Alcoholism	123
Alcohol withdrawal syndrome	123
Delirium Tremens (DTs)	123
Wernicke-Korsakoff syndrome	123
Drug use / abuse	123
Hallucinogenics	123
Opiates (heroin, morphine, oxycodone, codeine)	123
Stimulants (cocaine / amphetamines)	123
Benzodiaepams	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 *

Delusions	123
Hallucinations	123
Gastrointestinal Experience	123
GI assessment	123
NG tube insertion & management	123
Enterostomal 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 *

Pancreatitis	123
Hepatitis	123
G.I. bleed	123
Esophageal bleeding	123
Bowel obstruction	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 *

Anticholinergics (antispas, Bentyl or Robinul)	123
Cathartics	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 *

AV shunt/fistula	123
Catheter insertion	123
GU irrigations	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 *

Splints	123
Cast care	123
Cast removal	123
Ortho trauma	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 *

Staple/suture removal	123
Oncology	123
Chemotherapy	123
Leadership skills (team leader or charge nurse)	123
Supervision of unlicensed assistive personnel	123
Post mortem care	123
Training in over familiarization with inmates	123
Training in potential/actual weapon recognition	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. *