Name:
Email:
LAST 4 OF SSN:
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
Angina
ENT
Neurosurgical
Obstetrics
Open Heart
Orthopedics
Plastics
Trauma
Vascular
Accessory Medications
Adjuvant Medications
Blood Products
Fluids
Ketamine
Methohexital
Nitrous Oxide
Sodium Thiopental
Valium
Versed
Cardiovascular Status
COPA
Endotracheal Intubation
Fiber Optic Intubation
Nasal Intubation
Neuromuscular Status and Function
Oxygentation
Patient Positioning
Ventilation
Infection Control Practices
Interpretation of Lab Studies
IV General Anesthesia
IV Maintenance
Mask Induction and Maintenance
Total IV Anesthesia
Local
Caudal
Epidural
Subarachnoid Block
Nerve Block
Intercostal Block
Intravenous Regional
Local Infiltration Block
Major
Plexus
Retrobulbar
Transtracheal Block
Obtaining Accurate Pre-anesthesia Assessment
Recommend Appropriate Diagnostic Studies
Acute Care Hospital
Dentist Office
Plastic Surgery Center
Private Practice Office Setting
Epic
Cerner
Eclipsys
McKesson
Meditech
Other Computerized System
Computerized Physician Order Entry
Bar Coding for Medication Administration
Unit
No. Of Years
Burn
Critical Unit
PACU
Neurology
Telemetry
Medical
Surgical
Oncology
Operating Room
Emergency Room
Trauma Center Level 1
Community Er
Rural Er
Post Partum
Labor & Delivery
Newborn Nursery
Level II NICU
Level III NICU
PICU
Pediatrics
OB/GYN
Psychiatry
RRT
CRT
Newborn/Neonatal (birth – 30 days)
Infant (30 days-1 year)
Toddler (1-3 years)
Preschool (3-5 years)
School Age Children (5-12 years)
Adolescent (12-17 years)
Young Adults (18-44 years)
Middle Adults (45-64 years)
Older Adults (65 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.
