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AMBULATORY SKILLS 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 Patient Care | 1 | 2 | 3 | 4 | ||
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Admit and Assess Patients | ||||||
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Advance Directives | ||||||
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Collect Appropriate Data | ||||||
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Discharge Teaching | ||||||
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Preoperative Teaching | ||||||
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Patient Prep | ||||||
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Computerized Documentation | ||||||
| Rating Stars (Click) | Cardiovascular | 1 | 2 | 3 | 4 | ||
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Assess Heart Tones | ||||||
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Bedside Tele Monitoring | ||||||
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Interpretation of Coagulation Studies | ||||||
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Perform Pulses/Circulation Checks | ||||||
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Pre/Post Op Care Pacemaker | ||||||
| Rating Stars (Click) | Pulmonary | 1 | 2 | 3 | 4 | ||
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Assess Breath Sounds | ||||||
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Apply Oxygen | ||||||
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Interpret ABGs | ||||||
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Thoracentesis | ||||||
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Oximetry | ||||||
| Rating Stars (Click) | Neurology | 1 | 2 | 3 | 4 | ||
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Assess Neurological Signs | ||||||
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Epidurals | ||||||
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Selective Nerve Root Blocks | ||||||
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Level of Consciousness | ||||||
| Rating Stars (Click) | GI | 1 | 2 | 3 | 4 | ||
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Insertion/Monitoring NG Tubes | ||||||
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Assessment/Patient Care Continued | ||||||
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Flexible Sigmoidoscopy | ||||||
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Hemorrhoid Banding | ||||||
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Liver Biopsy | ||||||
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Paracentesis | ||||||
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Lap Band Surgery | ||||||
| Rating Stars (Click) | GU | 1 | 2 | 3 | 4 | ||
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Bladder Biopsy | ||||||
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Cystoscopy | ||||||
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Urethral Dilation | ||||||
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Nephrostomy | ||||||
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Kidney Biopsy | ||||||
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Suprapubic Catheter | ||||||
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Prostate Biopsy | ||||||
| Rating Stars (Click) | Endocrine | 1 | 2 | 3 | 4 | ||
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Care of Diabetic Patient | ||||||
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Diabetic Teaching | ||||||
| Rating Stars (Click) | ENT and Mouth | 1 | 2 | 3 | 4 | ||
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Prosthondontics – Restorative Dentistry | ||||||
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Mouth Biopsy | ||||||
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Myringotomy | ||||||
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Maxillofacial Prosthetics | ||||||
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Nose Biopsy | ||||||
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Thyroid Aspirate Biopsy | ||||||
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Fiberoptic Laryngoscopy | ||||||
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Tonsilectomy | ||||||
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Rhinoplasty | ||||||
| Rating Stars (Click) | Wounds/Integument | 1 | 2 | 3 | 4 | ||
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Application of Burn Dressings | ||||||
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Application of Dressing | ||||||
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Debridement of Wound | ||||||
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Wound Care | ||||||
| Rating Stars (Click) | OB/GYN | 1 | 2 | 3 | 4 | ||
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Electrodesiccation and Curettage (ED&C) | ||||||
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Nipple Reconstruction | ||||||
| Rating Stars (Click) | Musculoskeletal | 1 | 2 | 3 | 4 | ||
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Arthrocentesis | ||||||
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External Hardware and Pin Care | ||||||
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Arthroscopy | ||||||
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Open Reduction and Internal Fixation | ||||||
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Closed Reduction and Internal Fixation | ||||||
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Trigger Point Injections | ||||||
| Rating Stars (Click) | Plastics | 1 | 2 | 3 | 4 | ||
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Liposuction | ||||||
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Plastic Surgery | ||||||
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Cosmetic | ||||||
| Rating Stars (Click) | General Medications/Therapeutic Interventions | 1 | 2 | 3 | 4 | ||
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Administer IM and SQ Meds | ||||||
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Administer Inhalation Medications | ||||||
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Administer PO Medications | ||||||
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Bladder Irrigation and Instillation | ||||||
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Needleless Systems | ||||||
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Chemotherapy | ||||||
| Rating Stars (Click) | IV Therapy | 1 | 2 | 3 | 4 | ||
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Infusion Pumps | ||||||
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Peipheral IV Insertion | ||||||
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Syringe Pumps | ||||||
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Vascular Access Devices Care/Maintenance | ||||||
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Administer IV Medications | ||||||
| Rating Stars (Click) | Oxygen Administration | 1 | 2 | 3 | 4 | ||
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Ambu-Bug | ||||||
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Nasal Cannula | ||||||
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Non-ReBreather Mask | ||||||
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Pulse Oximetry | ||||||
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Venti Mask | ||||||
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Face Mask | ||||||
| Rating Stars (Click) | Nutritional Therapy | 1 | 2 | 3 | 4 | ||
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Lipids | ||||||
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TPN | ||||||
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Procalamine | ||||||
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Enteral Administration | ||||||
| Rating Stars (Click) | Pain Management/Anesthesia | 1 | 2 | 3 | 4 | ||
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Inplantable Narcotic Pump Re ll | ||||||
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Moderate Sedation | ||||||
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Epidural | ||||||
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Spinal | ||||||
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Local | ||||||
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General | ||||||
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Axillary Block | ||||||
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Bier Block | ||||||
| Rating Stars (Click) | Blood | 1 | 2 | 3 | 4 | ||
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Blood and Blood Products | ||||||
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Albumin | ||||||
| Rating Stars (Click) | General Procedures/Equipment | 1 | 2 | 3 | 4 | ||
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Apply Immobilizers (clavicle, knee, etc.) | ||||||
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Assist with Code Resuscitation | ||||||
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Assist with Lumbar Puncture | ||||||
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Laser | ||||||
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Dermabrasion | ||||||
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Drain Removal | ||||||
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Incision and Drainage | ||||||
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NGT Insertion | ||||||
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Patch Test | ||||||
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Punch Biopsy | ||||||
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Procedure Set Up | ||||||
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Procedures/Equipment Continued | ||||||
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Remove External Fixators With Pin | ||||||
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Scissor Biopsy | ||||||
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Scrub | ||||||
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Screw-Hardware Removal | ||||||
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Set-up Assist Suturing | ||||||
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Staple Removal | ||||||
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Straight/Foley Cath Female | ||||||
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Straight/Foley Cath Male | ||||||
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Suture Removal | ||||||
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TENS (Transcutaneous Elec. Nerve Stimulator) | ||||||
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Use of Doppler | ||||||
| Rating Stars (Click) | Specimen Collections | 1 | 2 | 3 | 4 | ||
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Venipuncture | ||||||
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Clean Catch Urine | ||||||
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Sterile Urine Collection | ||||||
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Stool | ||||||
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Sputum | ||||||
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Butter y Stick | ||||||
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Central Line Draw | ||||||
| Rating Stars (Click) | Clinical Settings | 1 | 2 | 3 | 4 | ||
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Surgi-Center | ||||||
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Out Patient Clinic | ||||||
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Age Group Experience Continued | ||||||
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Physician O ce | ||||||
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Ambulatory Surgery Clinic | ||||||
| Rating Stars (Click) | Joint Commission | 1 | 2 | 3 | 4 | ||
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National Safety Goals | ||||||
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“Do Not Use” Abbreviations and Terms | ||||||
| Rating Stars (Click) | Age Specific Competencies | 1 | 2 | 3 | 4 | ||
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Infant (Birth - 1 year) | ||||||
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Preschooler (ages 2-5 years) | ||||||
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Childhood (ages 6-12 years) | ||||||
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Adolescents (ages 13-21 years) | ||||||
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Young Adults (ages 22-39 years) | ||||||
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Adults (ages 40-64 years) | ||||||
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Older Adults (ages 65-79 years) | ||||||
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Elderly (ages 80+ years) | ||||||