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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
Advanced directives
Awareness of HCAHPS
Patient/family teaching
Discharge planning
UR/medicare review
Lift/transfer devices
Specialty beds
Restrictive devices (restraints)
End of life care/palliative care
Automated Medication Dispensing System, Pyxis, Omnicell, or other
National Patient Safety Goals
Accurate patient identification
Effective communication
Awareness of patient rights
Interpretation & communication of lab values
Medication administration
Labeling (medications & specimens)
Medication reconciliation
Anticoagulation therapy
Pain assessment & management
Infection control
Universal precautions
Isolation
Minimize risk for falls
Prevention of pressure ulcers
Assessment of heart sounds
Identification of arrhythmias (rate/rhythm)
Pacemakers/AID’s
Cardiac arrest/CPR
Hypertension
Pre/post MI
CHF
Post cardiac surgery
Fluid & electrolyte imbalances
Medication Administration
Anticoagulants
Antiarrhythmics
Beta blockers
Nitroglycerin
Diuretics
Assessment/auscultation of lung sounds
Establishing an airway
Chest PT
Incentive spirometry
Supplemental oxygen (cannula, facemask)
Tracheostomy care
Suctioning (tracheostomy & nasotracheal)
Nebulizer use
Care of Patient with
Pneumonia
Asthma
COPD
Emphysema
Use & Administration of
Bronchodilators
Expectorants
Corticosteroids
Assessment of neuro signs
Seizure precautions
TBI (Traumatic Brain Injury: history of)
Seizure activity
Spinal cord injury
Stroke (CVA)
Multiple sclerosis
Alzheimer’s disease
Parkinson’s disease
ALS (Amyotrophic Lateral Sclerosis)
Antiseizure medications
Antiemetics
Laxatives
Enemas
Bowel prep
NG tube (insertion/removal)
Long term feeding tubes (dobhoff/keofeed)
Gastrostomy tube
Tube feedings
Monitoring input/output
Colostomy/ileostomy
GI bleed
Feeding devices/adaptive equipment
Dietary restrictions
GT/PEG feedings
Foley catheter insertion/removal
GU irrigations
Nephrostomy tube
Suprapubic catheter
Ileo conduit
Use of bladder scan equipment
Shunts and fistulas
Straight catheterizations
Incontinence/bladder training
Chronic renal failure/dialysis
Peritoneal dialysis
Total joint replacement
Arthroscopic surgery
Cast care
Pulse/CMS checks
Suture/staple removal
Prosthesis application
Standard extremity braces
Amputation
Stump wrapping
Laminectomy
Assistive devices
CPM machines
Start & maintain Ivs
Blood draw: venous
Central line care (PICC)
Blood draw: central line PICC
Care & management of ports
Infusion pumps
Administration of blood/blood products
Wound care/surgical
Wound care/medical
Dressing changes
Skin assessment
Wound vac
Newborn/neonate (birth-30 days)
Infant (31 days-1 year)
Toddler (2-3 years)
Preschool (ages 4-5 years)
School age (ages 6-12 years)
Adolescents (ages 13-21 years)
Young adult (ages 22-39 years)
Adults (ages 40-64 years)
Older adult (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.
