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
Neonates < 28 Weeks
Neonates 29 - 34 Weeks
Neonates > 34 Weeks
Level II NICU
Level III NICU
Level IV NICU
Cardiac Surgery - Pre-op
Cardiac Surgery - Immediate Post-op
Congenital Heart Disease/Defects
CHF/Pulmonary Edema
Hemodynamic Instability
Bronchopulmonary Dysplasia
Diaphragmatic Hernia
Fresh Tracheostomy
Meconium Aspiration
Persistent Pulmonary Hypertension
Pneumonia
Respiratory Distress Syndrome/Failure
Interpretation of ABGs
Assist with Intubation/Extubation
Endotracheal Suctioning
Chest Tube Placement and Management
Modes of Ventilation (AC/PC/SIMV/CPAP/BiPAP)
High Frequency Ventilation
Inhaled NO
ECMO
Ballard/Dubowitz
Reflexes Based on Gestational Age
Hydrocephalus
Intraventricular Hemorrhage
Meningocele/Myelomeningocele
Neonatal Abstinence Score/Syndrome
Seizures
Colostomy/Ileostomy
Gastroschisis/Omphalocele
GI Bleeding
Necrotizing Enterocolitis
Post Abdominal Procedure
Breast Milk Handling/Storage
Breast Pump
Gavage Feedings
NG/OG/NJ Tube Placement and Management
Circumcision Care
Genetic Disorders
Hypo/Hyperglycemia
Infant of Diabetic Mother
Malformations of the GU Tract/Kidney
Phototherapy
Renal Failure
Neonatal Sepsis
Septic Work Up
Assist with Lumbar Puncture
Calculation of Neonatal Dosages
Antibiotics/Antivirals
Anticonvulsants
Immunizations
Digoxin
IV Vasopressors
Prostaglandin
Bronchodilators
Steroids
Caffeine
Automated Medication Dispensing (i.e. Pyxis, Omnicell)
Surfactant
Administration of Blood/Blood Products
Central Line Catheter/Dressings
Management of UAC/UVC Lines
Radial Arterial Lines
Start IVs
Attend High Risk Deliveries
Preparation for Transport
Transport Neonate
Rhythm Interpretation
Dysrhythmia Management
National Patient Safety Goals/Core Measures
Bereavement/Postmortem Care
Neonatal Skin Care
Pressure Ulcer Risk Assessment/Prevention
Restraints/Use of Least Restrictive Device
Patient/Family Teaching
Age Specific/Population-Based Care
Isolation Precautions
Infection Prevention
Pain Assessment & Management
Charge Experience
Interpretation and Communication of Lab Values
Epic
Cerner
Eclipsys
McKesson
Meditech
Other Computerized System
EMR Conversion
Computerized Physician Order Entry
Bar Coding for Medication Administration
BLS
5
CNRN
ACLS
CCRN
Other:
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.
