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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)

    CARDIAC

    Use of cardiac monitors

    Assessment of heart sounds

    Cardiac Arrest

    CPR

    Care of patients with CHF

    Atropine administration

    Digoxin administration

    Dopamine administration

    Inderal administration

    Lidocaine administration

    Rating Stars
    (Click)

    GENITOURINARY

    Fluid Balance

    Foley Catheter Insertion

    Ileostomy

    GU Irrigations

    Nephrostomy Tube

    Rating Stars
    (Click)

    ENDOCRINE

    Blood Glucose Checks

    Insulin Administration

    Care of patients with
    Diabetes

    Rating Stars
    (Click)

    GASTROINTESTINAL

    NG tube care and feedings

    Gastrostomy tube care and
    feedings

    Colostomy Care

    Assessment of Bowel Sounds

    Rating Stars
    (Click)

    LEADERSHIP/PATIENT CARE

    Taking Charge 

    Admission Procedures

    Discharge Procedures

    Patient Education

    Patient Care Plans

    Rating Stars
    (Click)

    MEDICATIONS/IV THERAPY

    Medication Calculation

    Reconstitution

    Oral Administration

    Eye Administration

    IM Administration

    SQ Administration

    Rectal Administration

    Starting IV’s

    IV Medication
    Administration

    Central Line Care

    Rating Stars
    (Click)

    NEUROLOGY

    Assessment of Neurological
    Status

    Seizure Precautions

    Care of a patient with a
    CVA

    Care of a patient with
    Alzheimer’s

    Care of patients with
    Spinal Cord Injury

    Decadron Administration

    Dilantin Administration

    Phenobarbital
    Administration

    Valium Administration

    Rating Stars
    (Click)

    ORTHO/SKIN

    Assessment of skin

    Wound Care and Treatments

    Use of special pressure
    relief devices

    Care of pts with a total
    hip replacement

    Care of pts with a total
    knee replacement

    Crutch Walking

    Rating Stars
    (Click)

    RESPIRATORY

    Pulse Oximetry

    Oxygen Administration via
    nasal cannuia

    Oxygen Administration via
    face mask

    Principles of chest
    percussion

    Care of patients with
    ventilator

    Care of patients with COPD

    Care of patients with ARDS

    Care of patient with a
    Tracheotomy

    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.