Proﬁciency Scale:

1 – Theory Only/No Experience - Didactic instruction only, no hands-on experience.

2 – Limited Experience - Knows procedure/has used equipment but has done so infrequently or not within the last six months.

3 – Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.

4 – Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.

Pulmonary

1

2

3

4

COPD

CPAP/BiPAP

Home Oxygen Administration

Lung Cancer

Oral/Nasotracheal Suctioning

Oxygen Safety Education

Pneumonia

Portable Oxygen

Pulmonary Emboli

Trach Care/Suctioning

Ventilator Management

Orthopedics

1

2

3

4

Amputation

Assistive Equipment/Lift Devices

Application of Cast/Brace

In Home PT/INR

Incision Checks

Joint Replacement

Staple Removal

Renal/Genitourinary

1

2

3

4

AV Fistula/Shunt

Bladder Catheter Insertion/Maintenance

Hemodialysis

Peritoneal Dialysis

Urostomy

Wound/Skin Care

1

2

3

4

Braden Scale

Burns

Pressure Ulcer Prevention/Staging/Management

Wound Care

Wound Cultures

Wound Vac

Infectious Disease

1

2

3

4

Infectious/Contagious/Communicable Disease

Isolation Precautions

Psychiatric

1

2

3

4

Cognitive Disorders

Management of an Aggressive Patient

Medication Compliance

Mood Disorders

Schizophrenia/Psychotic Disorders

Pediatrics

1

2

3

4

Bronchopulmonary Dysplasia

Cystic Fibrosis

Growth and Development

Muscular Dystrophy

Respiratory Distress Syndrome

Sickle Cell Disease

Spina Bifida

Spinal Surgery

Trach Care/Suctioning

Ventilator Management

Palliative and End of Life Care

1

2

3

4

Family Support/Teaching

Palliative Symptom Management

Postmortem Protocols

Home Health

1

2

3

4

Allscripts

APS (Adult Protective Services) Reports

Case Load

Age Specific:

Please indicate the frequency with which you provide care for each age group:

1

2

3

4

Infant (Birth to 1 year)

Toddler (1-3 years)

Pre-school (3-6 years)

School Age (6-12 years)

Adolescent (12-18 years)

Young Adult (18-30 years)

Mature Adult (30-60 years)

Elderly (>60 years)

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

Pulmonary

Neurological

Orthopedics

Gastrointestinal

Renal/Genitourinary

Endocrine/Metabolic

Wound/Skin Care

Oncology

Infectious Disease

Phlebotomy/IV Therapy

Psychiatric

Women's Health/Maternal-Infant Care:

Pediatrics

Pain Management

Palliative and End of Life Care

Medications

Home Health

Professional Knowledge and Skills

Age Specific: