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)

MM slash DD slash YYYY

Use of cardiac monitors
Assessment of heart sounds
Care of patients with CHF
Activities of daily living
Admission of patient
Administration of medication
Application of heat and cold
Aseptic Technique
Assist with medical examination
Bathing: Sitz, tub, bed, shower
Body Alignment
Body Systems Review (Head to Toe data collection)
Cast care
Catheterization / Foley catheter care
Colostomy Care and irrigation
Crutch walking
Decubitus Care
Diabetic tests and preparation forms
Diabetic blood glucose testing
Discharge patients
Dosage computation
Dressing (sterile)
Ear drops
Elimination needs
Enemas, cleansing, retention, Harris flush
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
Surgical Preps
Computerized charting
Trach care/suctioning
Telephone manners
Topical Medication Application
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
Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)
Elderly (ages 80+ years)