Skilled Nursing 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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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
Awareness of HCAHPS	123
Patient/family teaching	123
Discharge planning	123
UR/medicare review	123
Lift/transfer devices	123
Specialty beds	123
Restrictive devices (restraints)	123
End of life care/palliative care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Awareness of patient rights	123
Interpretation & communication of lab values	123
Medication administration	123
Labeling (medications & specimens)	123
Medication reconciliation	123
Anticoagulation therapy	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123

CARDIAC 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 heart sounds	123
Identification of arrhythmias (rate/rhythm)	123
Pacemakers/AID’s	123
Cardiac arrest/CPR	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 *

Hypertension	123
Pre/post MI	123
CHF	123
Post cardiac surgery	123
Fluid & electrolyte imbalances	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 *

Anticoagulants	123
Antiarrhythmics	123
Beta blockers	123
Nitroglycerin	123
Diuretics	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/auscultation of lung sounds	123
Establishing an airway	123
Chest PT	123
Incentive spirometry	123
Supplemental oxygen (cannula, facemask)	123
Tracheostomy care	123
Suctioning (tracheostomy & nasotracheal)	123
Nebulizer use	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 *

Pneumonia	123
Asthma	123
COPD	123
Emphysema	123

USE & ADMINISTRATION 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 *

Bronchodilators	123
Expectorants	123
Corticosteroids	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 *

Assessment of neuro signs	123
Seizure precautions	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 *

TBI (Traumatic Brain Injury: history of)	123
Seizure activity	123
Spinal cord injury	123
Stroke (CVA)	123
Multiple sclerosis	123
Alzheimer’s disease	123
Parkinson’s disease	123
ALS (Amyotrophic Lateral Sclerosis)	123

USE & ADMINISTRATION 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 *

Antiseizure medications	123
Antiemetics	123
Laxatives	123
Enemas	123
Bowel prep	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 *

NG tube (insertion/removal)	123
Long term feeding tubes (dobhoff/keofeed)	123
Gastrostomy tube	123
Tube feedings	123
Monitoring input/output	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 *

Colostomy/ileostomy	123
GI bleed	123
Feeding devices/adaptive equipment	123
Dietary restrictions	123
GT/PEG feedings	123

USE & ADMINISTRATION 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 *

Antiemetics	123
Laxatives	123
Enemas	123
Bowel prep	123

GENITOURINARY 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 *

Foley catheter insertion/removal	123
GU irrigations	123
Nephrostomy tube	123
Suprapubic catheter	123
Ileo conduit	123
Use of bladder scan equipment	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 *

Shunts and fistulas	123
Straight catheterizations	123
Incontinence/bladder training	123
Chronic renal failure/dialysis	123
Peritoneal dialysis	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 *

Total joint replacement	123
Arthroscopic surgery	123
Cast care	123
Pulse/CMS checks	123
Suture/staple removal	123
Prosthesis application	123
Standard extremity braces	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 *

Amputation	123
Stump wrapping	123
Laminectomy	123
Assistive devices	123
CPM machines	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 IVs	123
Blood draw: venous	123
Central line care (PICC)	123
Blood draw: central line PICC	123
Care & management of ports	123
Infusion pumps	123
Administration of blood/blood products	123

SKIN 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 *

Wound care/surgical	123
Wound care/medical	123
Dressing changes	123
Skin assessment	123
Wound vac	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. *