Medical/Surgical 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
Awareness of HCAHPS	123
Patient/family teaching	123
Computerized Documentation	123
Restraints	123
Lift/Transfer Devices	123
Specialty Beds	123
End of Life/Palliative Care	123
Automated Medication Dispensing Systems (Pyxis, Omnicell)	123
Bar Coding for medication administration	123
National Patient Safety Goals	123
Accurate Patient Identification	123
Interpretation and communication of lab values	123
Medication Administration 5 rights	123
Labeling (specimens, labs)	123
Medication Reconciliation	123
Pain Assessment and management	123
Infection Control	123
Universal Precautions	123
Isolation	123
Minimize risk for falls	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 *

Rapid Response Teams	123
Cardiac Arrest/ CPR	123
Oxygen therapy and delivery	123
Pulse oximetry	123
Use of Doppler/pulse checks	123
Automatic/manual Blood Pressure checks	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 and maintaining peripheral Iv’s	123
Blood Draw: venous	123
Multi Lumen Central line care and dressing changes	123
Blood Draw Central line	123
IV Push	123
Care & Management of Port a catheter	123
Care & Management of PICC/ Groshong/Hickman	123
TPN and Lipids	123
Administration of blood/blood products	123
Administration of Chemotherapy	123
Monitoring Chemotherapy (does not initiate)	123
IV drip calculations	123
IV fluids	123
Management of IV Infusion Pumps (Alaris, Baxter)	123
Management of elastomeric infusion	123
Management of intrathecal pumps	123

CARDIAC EXPERIENCE & CARE OF A 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 *

Auscultation of Irregular of Heart Sounds	123
Angina	123
Anticoagulation therapy	123
arrhythmias	123
Abdominal Aortic Aneurysm	123
Carotid Endarterectomy	123
Congestive heart Failure	123
Cardiomyopathy	123
Coagulation	123
Endocarditis	123
Femoral Popliteal Bypass	123
Hypertension	123
Pulse oximetry	123
Pericarditis	123
Peripheral Edema	123
Pulse/Circulation checks	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 *

Antihypertensive medications (Beta Blockers, Antiarrhythmics, Ace Inhibitors, Calcium Channel Blockers)	123
Inotropic: (digoxin)	123
Antiarrhythmics (Pacerone, Rythmol)	123
Beta Blockers (Sotalol, metroprolol)	123
Ace Inhibitors (Catopril, Ramipril, Vasotec)	123
Antianginals (isordil/nitrates)	123
Antilipemic: statins	123
Anticoagulation medications (heparin, Coumadin,	123
Diuretics	123

PULMONARY EXPERIENCE & CARE OF A 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 *

Assessment of abnormal breath sounds	123
Aspiration	123
Asthma	123
Emphysema	123
Airway management/suctioning (Oral, trach)	123
ABG’s recognition and treatment of abnormal values	123
Acute Pneumonia	123
Pneumothorax	123
Chest Tube care and management	123
COPD	123
Incentive spirometer	123
Pre/Post Thoracic Surgery	123
Lobectomy	123
Thoracentesis	123
Lung transplant	123
Oxygen administration	123
Ambu bag	123
Nasal Canula	123
Nebulizer treatments	123
Non-rebreather	123
Trach collar	123
Venti mask	123
TB	123
Tracheostomy Care	123
Bronchoscopy	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 *

Antihistamines	123
Bronchodilators	123
Expectorants and anti-tussins	123
inhalers	123
Steroids	123

NEUROLOGY EXPERIENCE & CARE OF A 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 *

Level of Consciousness	123
Comprehensive neuro assessment	123
Glasgow Coma Scale	123
CVA/ TIA	123
Intercranial Hemorrhage & hematoma	123
Reflex motor deficits	123
Visual communication deficit	123
CNS infection	123
Meningitis	123
Encephalitis	123
Alzheimer’s Disease	123
Delirium Tremens	123
Overdose	123
Neuromuscular disease	123
Multiple Sclerosis	123
Metastatic Tumor	123
Tumor resection	123
Pre/Post Neuro Surgery	123
Laminectomy	123
Assist Lumbar Puncture	123
Halo Traction	123
Seizure Disorder	123
Spinal Cord Injury	123
Traumatic Brain Injury	123

MEDICATION ADMINISTRATION 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 *

Anticonvulsants (Dilantin/ Phenobarbital)	123
Antidepressants	123
Antiparkinson’s (Cogentin/Levodopa/Sinemet)	123
Corticosteroids	123

GASTROINTESTINAL EXPERIENCE & CARE OF A 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 *

Assessment of Bowel Sounds	123
Nutritional Status	123
Interpretation of labs and electrolyte imbalance	123
Bowel Obstruction	123
EGD	123
Insertion and management of NG tube	123
Bowel Prep/Colonoscopy	123
ERPC	123
Nausea/vomiting	123
Constipation/impaction	123
diarrhea	123
Insertion and management of small-bore feeding tubes (Dubhoff, Keofeed)	123
Management and care of PEG tub/feed	123
Management and care of gastrostomy tube/feed	123
Management and care of jejunostomy tube/feed	123
Gravity/bolus feedings	123
Kangaroo pump	123
Management and care of ostomy	123
Abdominal wounds	123
Pre/Post abdominal surgery	123
Paralytic Ileus	123
Management of post-surgical drains	123
Gastric Bypass	123
Peritonitis	123
GI bleed (upper/lower)	123
Hepatitis	123
Inflammatory Bowel Disease	123
Liver Failure	123
Liver Cancer	123
Paracentesis	123
Pancreatic Cancer	123

MEDICATION ADMINISTRATION 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 *

Antiemetics	123
Antispasmodics	123
Anticholinergics	123
Laxatives	123

GENITOURINARY/RENAL EXPERIENCE & CARE OF A 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 *

Insertion and maintenance of urethral catheter	123
Care of Nephrostomy tube	123
Care of Suprapubic catheter	123
Fluid and Electrolyte disturbance	123
GU irrigation	123
Kidney Failure (acute/Chronic)	123
Measurement of Intake and Output Monitoring	123
Urine Retention	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 *

Pyelonephritis/UTI	123
BPH	123
TURP	123
Prostate Cancer	123
Nephrectomy	123
Ileoconduit	123
Renal Surgery	123
Hemodialysis	123
Peritoneal Dialysis	123
Shunts/Fistulas	123
Obstructions	123
Renal Trauma	123
Testicular Torsion	123

ORTHOPEDIC EXPERIENCE & CARE OF A 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 *

Assess Range of Motion	123
Assessment of color, warmth, movement, sensation	123
Amputation	123
Cast Care	123
Fractures	123
Splints	123
Traction	123
Trauma	123
Strains/Sprain	123
immobilization	123

METABOLIC/ENDOCRINE EXPERIENCE & CARE OF A 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 *

Diabetes	123
Blood Glucose Monitoring	123
Cushing’s Syndrome	123
Thyroid Disease	123
Post Thyroidectomy Care	123

SKIN/INTEGUMENTARY & CARE OF A 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 *

Skin assessment	123
Skin Breakdown monitoring	123
Staged Pressure Ulcers	123
Stasis Ulcers	123
Sterile dressing changes	123
Wound Vac maintenance and dressing changes	123

AGE-SPECIFIC 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. *