Proﬁciency Scale:

1 – No Experience

2 – Need Training

3 – Able to perform with supervision

4 – Able to perform independently

GENITOURINARY

1

2

3

4

Fluid Balance

Foley Catheter Insertion

Ileostomy

GU Irrigations

Nephrostomy Tube

GASTROINTESTINAL

1

2

3

4

NG tube care and feedings

Gastrostomy tube care and feedings

Colostomy Care

Assessment of Bowel Sounds

MEDICATIONS/IV THERAPY

1

2

3

4

Medication Calculation

Reconstitution

Oral Administration

Eye Administration

IM Administration

SQ Administration

Rectal Administration

Starting IV’s

IV Medication Administration

Central Line Care

ORTHO/SKIN

1

2

3

4

Assessment of skin

Wound Care and Treatments

Use of special pressure relief devices

Care of pts with a total hip replacement

Care of pts with a total knee replacement

Crutch Walking

Age Speciﬁc Competencies

1

2

3

4

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)

Please list any additional areas of expertise below:

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:

CARDIAC

GENITOURINARY

ENDOCRINE

GASTROINTESTINAL

LEADERSHIP/PATIENT CARE

MEDICATIONS/IV THERAPY

NEUROLOGY

ORTHO/SKIN

RESPIRATORY

Age Speciﬁc Competencies