Personal Information

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Proﬁciency Scale:

1 – Cannot Perform Skills Independently

2 – Requires Some Assistance to Perform Skills

3 – Can Perform Skill Independently

4 – Not Applicable

Neonatal assessments - High Risk Psychosocial Issues:

Family planning

WIC

High-risk follow-up

Housing

Financial aid

List criteria for identification of abuse victims:

Infant/child

Adolescent

Elderly

Domestic abuse

Fiduciary

Neglect

Documentation - Progress Notes:

Assessment of the situation

Adjustment to the illness and facility care/services

Possible solutions, options

Action taken

Disposition of case

Any social therapy/rehabilitation provided to patient and/or family

Follow-up notes

Documentation complete and appropriate in the medical record

Each entry is legible and authenticated

Maintains statistical data

Facility Environment - Able to locate and/or demonstrate knowledge of:

facility directory

Physician directory

Telephone system

Beeper system

Fax

Computer system

Charge system

Fire Equipment

Alarms

Fire extinguishers

Exit doors

Facility Resources - Able to locate and/or demonstrate the use of:

Policy and Procedure Manual

Fire/Safety Manual

Emergency Management Manual

Safety Data Sheets (SDS) Manual

Infection Prevention and Control Manual

Patient Teaching Aids/Materials

Exposure Control Plan

Community Resources File/Manual

QAPI Documentation

Corporate Compliance Program/Manual

Other

Cultural Factors:

Religion

Food preferences

Family/community relationships

Healthcare attitudes/understanding

Trust/privacy needs

Socioeconomic environment

Age Speciﬁc Competencies

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:

Skills

Neonatal assessments - High Risk Psychosocial Issues:

Education takes into consideration:

List criteria for identification of abuse victims:

New problems, changes in problems and/or resolution of problems are identified and followed through with:

Documentation - Progress Notes:

Care Plans:

Facility Environment - Able to locate and/or demonstrate knowledge of:

Facility Organization - Able to describe roles and functions of:

Facility Resources - Able to locate and/or demonstrate the use of:

Facility Routines - Able to describe, locate and /or demonstrate knowledge of: Communication System

Cultural Factors:

SKILLED ENVIRONMENTS

Age Speciﬁc Competencies