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Skilled Nursing Checklist | ||||||
| NAME | |||||||
| LAST 4 OF SSN | |||||||
| DATE | |||||||
| 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. | |||||||
| Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below. | |||||||
| Proficiency Scale: |
1 = No Experience 2 = Need Training 3 = Able to perform with supervision 4 = Able to perform independently |
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| Rating Stars (Click) | General Skills | 1 | 2 | 3 | 4 | ||
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Advanced directives | ||||||
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Awareness of HCAHPS | ||||||
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Patient/family teaching | ||||||
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Discharge planning | ||||||
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UR/medicare review | ||||||
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Lift/transfer devices | ||||||
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Specialty beds | ||||||
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Restrictive devices (restraints) | ||||||
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End of life care/palliative care | ||||||
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Automated Medication Dispensing System, Pyxis, Omnicell, or other | ||||||
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National Patient Safety Goals | ||||||
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Accurate patient identification | ||||||
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Effective communication | ||||||
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Awareness of patient rights | ||||||
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Interpretation & communication of lab values | ||||||
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Medication administration | ||||||
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Labeling (medications & specimens) | ||||||
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Medication reconciliation | ||||||
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Anticoagulation therapy | ||||||
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Pain assessment & management | ||||||
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Infection control | ||||||
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Universal precautions | ||||||
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Isolation | ||||||
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Minimize risk for falls | ||||||
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Prevention of pressure ulcers | ||||||
| Rating Stars (Click) | Cardiac | 1 | 2 | 3 | 4 | ||
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Assessment of heart sounds | ||||||
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Identification of arrhythmias (rate/rhythm) | ||||||
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Pacemakers/AID’s | ||||||
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Cardiac arrest/CPR | ||||||
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Hypertension | ||||||
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Pre/post MI | ||||||
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CHF | ||||||
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Post cardiac surgery | ||||||
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Fluid & electrolyte imbalances | ||||||
| Medication Administration | |||||||
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Anticoagulants | ||||||
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Antiarrhythmics | ||||||
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Beta blockers | ||||||
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Nitroglycerin | ||||||
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Diuretics | ||||||
| Rating Stars (Click) | Respiratory | 1 | 2 | 3 | 4 | ||
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Assessment/auscultation of lung sounds | ||||||
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Establishing an airway | ||||||
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Chest PT | ||||||
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Incentive spirometry | ||||||
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Supplemental oxygen (cannula, facemask) | ||||||
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Tracheostomy care | ||||||
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Suctioning (tracheostomy & nasotracheal) | ||||||
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Nebulizer use | ||||||
| Care of Patient with: | |||||||
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Pneumonia | ||||||
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Asthma | ||||||
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COPD | ||||||
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Emphysema | ||||||
| Use & Administration of: | |||||||
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Bronchodilators | ||||||
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Expectorants | ||||||
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Corticosteroids | ||||||
| Rating Stars (Click) | Neurology | 1 | 2 | 3 | 4 | ||
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Assessment of neuro signs | ||||||
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Seizure precautions | ||||||
| Care of Patient with: | |||||||
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TBI (Traumatic Brain Injury: history of) | ||||||
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Seizure activity | ||||||
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Spinal cord injury | ||||||
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Stroke (CVA) | ||||||
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Multiple sclerosis | ||||||
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Alzheimer’s disease | ||||||
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Parkinson’s disease | ||||||
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ALS (Amyotrophic Lateral Sclerosis) | ||||||
| Use & Administration of: | |||||||
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Antiseizure medications | ||||||
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Antiemetics | ||||||
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Laxatives | ||||||
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Enemas | ||||||
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Bowel prep | ||||||
| Rating Stars (Click) | Gastrointestinal | 1 | 2 | 3 | 4 | ||
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NG tube (insertion/removal) | ||||||
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Long term feeding tubes (dobhoff/keofeed) | ||||||
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Gastrostomy tube | ||||||
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Tube feedings | ||||||
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Monitoring input/output | ||||||
| Care of Patient with: | |||||||
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Colostomy/ileostomy | ||||||
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GI bleed | ||||||
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Feeding devices/adaptive equipment | ||||||
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Dietary restrictions | ||||||
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GT/PEG feedings | ||||||
| Use & Administration of: | |||||||
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Antiemetics | ||||||
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Laxatives | ||||||
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Enemas | ||||||
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Bowel prep | ||||||
| Rating Stars (Click) | Gastrointestinal | 1 | 2 | 3 | 4 | ||
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Foley catheter insertion/removal | ||||||
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GU irrigations | ||||||
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Nephrostomy tube | ||||||
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Suprapubic catheter | ||||||
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Ileo conduit | ||||||
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Use of bladder scan equipment | ||||||
| Care of Patient with: | |||||||
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Shunts and fistulas | ||||||
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Straight catheterizations | ||||||
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Incontinence/bladder training | ||||||
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Chronic renal failure/dialysis | ||||||
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Peritoneal dialysis | ||||||
| Rating Stars (Click) | Orthopedic | 1 | 2 | 3 | 4 | ||
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Total joint replacement | ||||||
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Arthroscopic surgery | ||||||
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Cast care | ||||||
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Pulse/CMS checks | ||||||
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Suture/staple removal | ||||||
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Prosthesis application | ||||||
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Standard extremity braces | ||||||
| Care of Patient with: | |||||||
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Amputation | ||||||
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Stump wrapping | ||||||
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Laminectomy | ||||||
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Assistive devices | ||||||
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CPM machines | ||||||
| Rating Stars (Click) | IV Therapy | 1 | 2 | 3 | 4 | ||
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Start & maintain Ivs | ||||||
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Blood draw: venous | ||||||
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Central line care (PICC) | ||||||
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Blood draw: central line PICC | ||||||
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Care & management of ports | ||||||
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Infusion pumps | ||||||
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Administration of blood/blood products | ||||||
| Rating Stars (Click) | Skin | 1 | 2 | 3 | 4 | ||
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Wound care/surgical | ||||||
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Wound care/medical | ||||||
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Dressing changes | ||||||
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Skin assessment | ||||||
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Wound vac | ||||||
| Rating Stars (Click) | Age Specific Competencies | 1 | 2 | 3 | 4 | ||
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Newborn/neonate (birth-30 days) | ||||||
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Infant (31 days-1 year) | ||||||
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Toddler (2-3 years) | ||||||
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Preschool (ages 4-5 years) | ||||||
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School age (ages 6-12 years) | ||||||
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Adolescents (ages 13-21 years) | ||||||
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Young adult (ages 22-39 years) | ||||||
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Adults (ages 40-64 years) | ||||||
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Older adult (ages 65-79 years) | ||||||
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Elderly (ages 80+ years) | ||||||
| Please list any Additional Skills: | |||||||
| 1 | |||||||
| 2 | |||||||
| 3 | |||||||
| 4 | |||||||
| Additional training: | |||||||
| 1 | |||||||
| 2 | |||||||
| 3 | |||||||
| 4 | |||||||
| Additional equipment: | |||||||
| 1 | |||||||
| 2 | |||||||
| 3 | |||||||
| 4 | |||||||