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    Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

    Proficiency Scale:

    1 = No Experience (Theory or observation only during the past 12 months)

    2 = Limited Experience (Performed less than 12 times within the past 12 months and may need a review)

    3 = Experienced (Performed at least once per month within the past 12 months and may need minimal assistance)

    4 = Highly Skilled (Performed on at least a weekly basis over the past 12 months; proficient)

    Rating Stars (Click)

    Skills

    Activities of daily living

    Admission of patient

    Administration of
    medication

    Ambulation

    Application of heat and
    cold 

    Aseptic Technique 

    Assist with medical
    examination

    Bathing: Sitz, tub, bed,
    shower

    Bandaging 

    Binders

    Body Alignment

    Body Systems Review (Head
    to Toe data collection)

    Cast care 

    Catheterization / Foley
    catheter care

    Charting 

    Colostomy Care and
    irrigation

    CPR

    Crutch walking

    Decubitus Care 

    Diabetic tests and
    preparation forms 

    Diabetic blood glucose
    testing 

    Discharge patients

    Dosage computation 

    Draping

    Dressing (sterile) 

    Ear drops

    Elimination needs

    Enemas, cleansing,
    retention, Harris flush 

    Restraints

    Infection Control: Standard
    Universal Precautions

    Infection Control: Reverse
    Isolation

    Infection Control: TB/
    Airborne Precautions

    Infections Control: MRSA/
    VRE Precautions

    Isolation procedure for
    specimen collection

    IVs: Monitor rate and
    infusion site

    Medications: Oral, IM, SQ

    Mouth care

    Nail Care

    Neurological Check

    Nutritional check

    Observations: Response to
    treatments/ meds

    Observations: Signs of
    significant body system changes

    Observations: Signs of
    shock

    Observations: Signs of pain

    Observes safety procedures

    O2 administration

    Pain assessment

    Patient care plans (revise
    and update)

    Patient safety standards/
    precautions

    Positioning patient

    Postural drainage

    Pre-op and post-op care

    Provide comfort, safety and
    privacy

    Pulse oxymetry

    Range of motion

    Report observations/
    changes

    Hand hygiene

    Skin care

    Specimen collection:
    routine urine

    Specimen collection: clean
    catch 

    Specimen collection: 12
    & 24 hour specimen 

    Specimen collection:
    stool 

    Specimen collection:
    culture

    Specimen collection:
    sputum 

    Specimen collection: from
    foley catheter

    Suppositories

    Suction-oral

    Surgical Preps

    Computerized charting 

    Trach care/suctioning

    Telephone manners

    Topical Medication
    Application

    Traction

    Transfer/ transport
    patients: wheelchair

    Transfer/ transport
    patients: gurney

    Transfer/ transport
    patients: to chair

    Urine test for glucose/
    acetone

    Vital Signs

    Weight: Bed scales and
    standing scales

    IV therapy certified

    Rating Stars
    (Click)

    Age Specific Competencies

    Infant (Birth - 1 year)

    Preschooler (ages 2-5
    years)

    Childhood (ages 6-12 years)

    Adolescents (ages 13-21
    years)

    Young Adults (ages 22-39
    years)

    Adults (ages 40-64 years)

    Older Adults (ages 65-79
    years)

    Elderly (ages 80+ years)

    By submitting this checklist, I hereby certify that ALL information I have provided to FILL IN THE BLANK on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.