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This checklist was electronically signed on (Today’s date)
This checklist is designed to guide our client facilities in assessing your proficiency in your nursing specialty. Please use the scale provided to indicate your level of experience and expertise in each of the areas listed below.
Skill Level Indicator:
★ = No Experience
★★ = Requires Training
★★★ = Capable with Supervision
★★★★ = Capable Independently
Admit and Assess Patients
Advance Directives
Collect Appropriate Data
Discharge Teaching
Preoperative Teaching
Patient Prep
Computerized Documentation
Assess Heart Tones
Bedside Tele Monitoring
Interpretation of Coagulation Studies
Perform Pulses/Circulation Checks
Pre/Post Op Care Pacemaker
Assess Breath Sounds
Apply Oxygen
Interpret ABGs
Thoracentesis
Oximetry
Assess Neurological Signs
Epidurals
Selective Nerve Root Blocks
Level of Consciousness
Insertion/Monitoring NG Tubes
Assessment/Patient Care Continued
Flexible Sigmoidoscopy
Hemorrhoid Banding
Liver Biopsy
Paracentesis
Lap Band Surgery
Bladder Biopsy
Cystoscopy
Urethral Dilation
Nephrostomy
Kidney Biopsy
Suprapubic Catheter
Prostate Biopsy
Care of Diabetic Patient
Diabetic Teaching
Prosthondontics – Restorative Dentistry
Mouth Biopsy
Myringotomy
Maxillofacial Prosthetics
Nose Biopsy
Thyroid Aspirate Biopsy
Fiberoptic Laryngoscopy
Tonsilectomy
Rhinoplasty
Application of Burn Dressings
Application of Dressing
Debridement of Wound
Wound Care
Electrodesiccation and Curettage (ED&C)
Nipple Reconstruction
Arthrocentesis
External Hardware and Pin Care
Arthroscopy
Open Reduction and Internal Fixation
Closed Reduction and Internal Fixation
Trigger Point Injections
Liposuction
Plastic Surgery
Cosmetic
Administer IM and SQ Meds
Administer Inhalation Medications
Administer PO Medications
Bladder Irrigation and Instillation
Needleless Systems
Chemotherapy
Infusion Pumps
Peipheral IV Insertion
Syringe Pumps
Vascular Access Devices Care/Maintenance
Administer IV Medications
Ambu-Bug
Nasal Cannula
Non-ReBreather Mask
Pulse Oximetry
Venti Mask
Face Mask
Lipids
TPN
Procalamine
Enteral Administration
Inplantable Narcotic Pump Re ll
Moderate Sedation
Epidural
Spinal
Local
General
Axillary Block
Bier Block
Blood and Blood Products
Albumin
Apply Immobilizers (clavicle, knee, etc.)
Assist with Code Resuscitation
Assist with Lumbar Puncture
Laser
Dermabrasion
Drain Removal
Incision and Drainage
NGT Insertion
Patch Test
Punch Biopsy
Procedure Set Up
Procedures/Equipment Continued
Remove External Fixators With Pin
Scissor Biopsy
Scrub
Screw-Hardware Removal
Set-up Assist Suturing
Staple Removal
Straight/Foley Cath Female
Straight/Foley Cath Male
Suture Removal
TENS (Transcutaneous Elec. Nerve Stimulator)
Use of Doppler
Venipuncture
Clean Catch Urine
Sterile Urine Collection
Stool
Sputum
Butter y Stick
Central Line Draw
Surgi-Center
Out Patient Clinic
Age Group Experience Continued
Physician O ce
Ambulatory Surgery Clinic
National Safety Goals
“Do Not Use” Abbreviations and Terms
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)
I hereby certify that ALL information I have provided 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.
