Proﬁciency Scale:

1 – Limited or no experience

2 – Experienced, but may need review or supervision

3 – Able to function independently

GENERAL SKILLS EXPERIENCE

1

2

3

Advanced directives

Awareness of HCAHPS

Patient/family teaching

Computerized Documentation

Restraints

Lift/Transfer Devices

Specialty Beds

End of Life/Palliative Care

Automated Medication Dispensing Systems (Pyxis, Omnicell)

Bar Coding for medication administration

National Patient Safety Goals

Accurate Patient Identification

Interpretation and communication of lab values

Medication Administration 5 rights

Labeling (specimens, labs)

NEUROLOGY EXPERIENCE

1

2

3

Level of Consciousness

Comprehensive neuro assessment

Glasgow Coma Scale

CVA/ TIA

Intercranial Hemorrhage & hematoma

Reflex motor deficits

Visual communication deficit

CNS infection

Meningitis

Encephalitis

Alzheimer’s Disease

Delirium Tremens

Overdose

Neuromuscular disease

Multiple Sclerosis

GASTROINTESTINAL EXPERIENCE

1

2

3

Assessment of Bowel Sounds

Nutritional Status

Interpretation of labs and electrolyte imbalance

Bowel Obstruction

EGD

CARE OF PATIENTS WITH:

1

2

3

Pyelonephritis/UTI

BPH

TURP

Prostate Cancer

Nephrectomy

Ileoconduit

Renal Surgery

Hemodialysis

Peritoneal Dialysis

Shunts/Fistulas

Obstructions

Renal Trauma

Testicular Torsion

AGE-SPECIFIC EXPERIENCE

1

2

3

Newborn / neonate (birth-30 days)

Infant (31 days-1 year)

Toddler (ages 2-3 years)

Preschool (ages 4-5 years)

School age (ages 6-12 years)

Adolescent (ages 13-21 years)

Young adult (ages 22-39 years)

Adult (ages 40-64 years)

Older adult (ages 65-79 years)

Elderly (ages 80+ 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:

WORK SETTING EXPERIENCE

GENERAL SKILLS EXPERIENCE

MEDICATION ADMINISTRATION

NEUROLOGY EXPERIENCE

MEDICATION ADMINISTRATION USE & ADMINISTRATION OF THE FOLLOWING

GASTROINTESTINAL EXPERIENCE

GENITOURINARY/RENAL EXPERIENCE

CARE OF PATIENTS WITH:

METABOLIC/ENDOCRINE EXPERIENCE

AGE-SPECIFIC EXPERIENCE