Personal Information

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Proﬁciency Scale:

1 – No experience; Theory/observed only

2 – Limited competency; < 5 times per year; Needs supervision

3 – Acceptable competency; > 5 times per year

4 – Competent; Performs on a daily or weekly basis; Proficient

I certify that all the above information is correct, and that any misrepresentation or falsification of fact may be considered sufficient cause for immediate dismissal from the agency. I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.

Personal Information

Proﬁciency Scale:

CARDIOVASCULAR

Assessment

Interpretation of lab results

Equipment usage & procedure

Monitoring

Pacemaker

Assisting with:

Care of the patient with:

Medications

PULMONARY

Assessment

Equipment usage & procedure

Airway management devices

Assist with:

O2 therapy & med delivery systems

Equipment usage & procedure

Care of the patient with:

Medications

EMR

PAIN MANAGEMENT

Care of the patient with:

MISCELLANEOUS

Care of the patient with:

NEUROLOGICAL

Assessment:

Equipment usage & procedure:

Care of the patient with:

Medications

GASTROINTESTINAL

Assessment

Interpretation of lab results

Equipment usage & procedure

Care of the patient with:

Medications

RENAL / GENITOURINARY

Equipment usage & procedure

Insertion & care of:

Care of the patient with:

ENDOCRINE / METABOLIC

Interpretation of lab results

Equipment usage & procedure

Care of the patient with:

WOUND MANAGEMENT

Assessment of:

Equipment usage & procedure

Care of the patient with:

PHLEBOTOMY / IV THERAPY

Equipment usage & procedure

Cryoprecipitate

Care of the patient with:

AGE SPECIFIC PRACTICE CRITERIA