Proﬁciency Scale:

1 – No Experience

2 – Need Training

3 – Able to perform with supervision

4 – Able to perform independently

CARDIOVASCULAR

1

2

3

4

Congenital Heart Disease/Repair

Pre Cardiac Surgery

Post Cardiac Surgery

Heart Sounds

NEUROLOGIC/ORTHOPEDIC

1

2

3

4

Brain Injury

Spinal Cord Injury

Seizure Disorders

Meningitis

Neuromuscular Disease

Extremity Fracture/Cast

Post Vertebral Surgery

Traction - General

Traction - Halo

Pin Care

VP Shunts/Internal/External

RENAL/GENITOURINARY

1

2

3

4

Circumcision

Testicular Torsion

Glomerulonephritis

Renal Failure

Renal Transplant

Urinary Retention

Bladder Scan

Insertion/Management of Bladder Catheters

Management of Suprapubic Catheters

ONCOLOGY

1

2

3

4

Chemotherapy Administration

Hodgkin's Disease

Hemophilia

Sickle Cell Anemia

Leukemia

Solid Tumors

Bone Marrow Transplant

MEDICATIONS

1

2

3

4

Pediatric Dosage Calculations

Anti-Hypertensives

Anticoagulants

Anti-Seizure Medications

Benzodiazepines

Digoxin

Diuretics

Emergency Medications

Inhaled Medications

Insulin

Narcotics/Opioid Analgesics (IV/Oral/Injection)

Non-Opioid Analgesics (IV/Oral/Injection)

Procedural Sedation - Recovery

Reversal Agents

Steroids (IV/Oral/Inhaled)

Automated Medication Dispensing (i.e. Pyxis, Omnicell)

CARDIAC MONITORING & EMERG. RESPONSE

1

2

3

4

Pediatric Early Warning Score (PEWS)/Rapid Response Team

Dysrhythmia Interpretation

Dysrhythmia Management

EMR

1

2

3

4

Epic

Cerner

Eclipsys

McKesson

Meditech

Other Computerized System

Computerized Physician Order Entry

Bar Coding for Medication Administration

Certifications	Expiration Date:
BLS
PALS
CPHON
Chemo Certification: Specify
PICC Certification: Specify
Other: Specify

Please list any additional skills/training/equipment:

Skills:

Training

Equipment:

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:

WORK SETTINGS

CARDIOVASCULAR

PULMONARY

NEUROLOGIC/ORTHOPEDIC

GASTROINTESTINAL

RENAL/GENITOURINARY

ENDOCRINE/METABOLIC

ONCOLOGY

INFECTIOUS DISEASE

MEDICATIONS

IV THERAPY

CARDIAC MONITORING & EMERG. RESPONSE

PROFESSIONAL KNOWLEDGE AND SKILLS

EMR

AGE SPECIFIC COMPETENCIES

Please list any additional skills/training/equipment: