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
PICU
Pediatric CVICU
Pediatric Step Down
Pediatric PACU
Congenital Heart Disease/Repair
Post Cardiac Surgery (Directly from OR)
Post Cardiac Surgery (NOT Directly from OR)
Post Diagnostic/Interventional Cardiac Cath
Heart Failure/Cardiogenic Shock
Cardiac Transplant
Hemodynamic Monitoring
Arrhythmia Interpretation
Pacemaker - Temporary/Permanent
SVO2 Monitoring
Intra-Aortic Balloon Pump
ECMO
Respiratory Distress Syndrome/Resp. Failure
Reactive Airway Disease
ENT Surgery
Epiglottis
Cystic Fibrosis
Tuberculosis
Intubation/Extubation
Endotracheal Tube Management
Tracheostomy Management
Modes of Ventilation: AC/PC/SIMV/CPAP
Modes of Ventilation: Jet/Oscillator
Nitric Oxide
Hemo/Pneumothorax
Brain Injury
Craniotomy
Spinal Cord Injury
Seizure Disorders
ICP Monitoring
VP Shunt
Meningitis
Neuromuscular Disease
Post Vertebral Surgery
Traction - General
Traction - Halo
Acute Surgical Abdomen
GI Bleeding
Pancreatitis
Hepatic Failure
Ostomy Management
Management of Gastric Tubes
Breast Milk Handling/Storage
Nephrotic Syndrome
Renal Transplant
Renal Replacement Therapy
Peritoneal Dialysis
Diabetes - Hypo/Hyperglycemic Crisis
Diabetic Ketoacidosis
IV Insulin Pumps
Indwelling Insulin Pumps
Blunt/Penetrating Trauma
Burns
Craniofacial Reconstruction
Near Drowning
Poison Ingestion/Overdose
Bites-Animal/Snake/Human
Suicide Precautions
Wound Management/VAC
Specialty Beds
Bone Marrow Transplant
Immunosuppressive Disorder
Hemophilia Crisis
Sickle Cell Crisis
Pediatric Dosage Calculations
Anti-Arrhythmics
Anticoagulants (IV, Oral and Injection)
Anti-Hypertensives
Anti-Seizure Medications
Benzodiazepines
Continuous IV Paralytics
Continuous IV Sedation
Procedural Sedation - Administration
Diuretics
Emergency Medication
Inhaled Medications
Insulin
IV Vasopressors
Narcotics/Opioid Analgesics (IV, Oral and Injection)
Non-Opioid Analgesics (IV, Oral and Injection)
Reversal Agents
Steroids (IV, Oral, Inhaled)
Automated Medication Dispensing (i.e. Pyxis, Omnicell)
Starting Ivs
Central Line Blood Draw
Central Line/Implanted Line Care
TPN/Lipids
Blood Product Administration
Administration of Chemotherapy
Dysrhythmia Interpretation
Dysrhythmia Management
Management of Cardiac Arrest
Shock Management
Malignant Hyperthermia
Multisystem Organ Failure
National Patient Safety Goals/Core Measures
Recognize/Report Signs of Abuse
EMTALA
Fall Risk Assessment/Prevention
Pressure Ulcer Risk Assessment/Prevention
Restraints/Use of Least Restrictive Device
Normal Growth and Development
Age Specific/Population Based Care
Patient Family Teaching
Isolation Precautions
Infection Prevention
Reporting Communicable Diseases
Pain Assessment And Management
Charge Experience
Interpretation and Communication of Lab Values
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)
Epic
Cerner
Eclipsys(RSV)
McKesson
Meditech
Other Computerized System
Computerized Physician Order Entry
Bar Coding for Medication Administration
EMR Conversion
BLS
PALS
ACLS
PEARS
ENPC
CEN
TNCC
Other: Specify
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.
