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
Working with patients in isolation
Working with patients in restraints
Patient/Family teaching
Patient Identification
Specialty beds
End of life care / palliative care
Knowledge of: Do Not Use Abbreviations
Do you have charge/supervisor experience?
Knowledge of current Joint Commission National Patient Safety Goals
Knowledge/familiarity with HCAHPS scores
Durable Medical Equipment (DME)
Managed Care
SNF/ Long Term Care
Home Health
Hospice
Outpatient
Physician Office
Concepts of capital budgeting
Department/unit budgeting
Recruitment techniques
Interviewing techniques
Labor Laws pertaining to hiring
Orientation of new employees
Knowledge of quality improvement / performance improvement tools
Patient Safety
Workplace safety
Promotion of interdepartmental communication
Performance management
Staff Development
Coaching and mentoring
Project management
Business development
Developing Strategic plans
Developing operational plans
Cultural competence
Personal growth and development
Ethical behavior and practice
Professional association involvement
Conflict Management
Team dynamics
Mediation/coaching
TJC Standards
OSHA Standards
Risk Management/Service Utilization
Local Department of Health
State Department of Health
Sitter Services
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.
