Proﬁciency Scale:

1 – Theory – No Experience

2 – Minimal Experience (0-12 Months)

3 – Experienced/Competent (Greater than 12 Months)

4 – Able to Teach/Supervise

BLOOD AND BLOOD PRODUCTS

1

2

3

4

Blood draws

Administration of whole blood

Administration of packed cells

Plasma/Extenders

Lipids/Albumin

CALCULATIONS

1

2

3

4

IV Rate Calculation

Unit Dose System

Dosage Calculation

IV Pump

CARE OF PATIENT WITH:

1

2

3

4

PCA Pump

IV Conscious Sedation

Epidural Anesthesia / Analgesia

MANAGEMENT OF INFECTIOUS DISEASES – WOUND CARE

1

2

3

4

Collection of Cultures / Procedures involving: Sputum

Collection of Cultures / Procedures involving: Stool

Collection of Cultures / Procedures involving: Blood

Collection of Cultures / Procedures involving: Wound

Collection of Cultures / Procedures involving: CSF

Universal Precautions

Isolation / Reverse Isolation Technique

Infection Disease Reporting

Fever Management

Sterile Dressings

Decubitus Care

SETTINGS

1

2

3

4

Acute Care

Inpatient Acute Rehab

Day Treatment Center

Skilled Nursing Facility

Home Health

Outpatient

Early Intervention

Pediatrics/School Age

Private Practice

Certifications	Expiration Date:
CPR
BLS
BCLS
ACLS
Other

Licensure(s) Number(s)	State(s)

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.

AREAS OF EXPERTISE	INPATIENT-MONTHS	INPATIENT-YEARS	OUTPATIENT-MONTHS	OUTPATIENT-YEARS
General Acute Care
Rehabilitation Hospital
Sports Medicine Clinic
Children’s Hospital
School System
Home Health Care
Physician’s Office
Skilled Nursing Facility
Management Duties

Personal Information

Proﬁciency Scale:

IV THERAPY (LINE INSERTION AND MAINTENANCE)

BLOOD AND BLOOD PRODUCTS

ADMINISTRATION OF MEDICATIONS

CALCULATIONS

PAIN MANAGEMENT (ASSESSMENTS)

CARE OF PATIENT WITH:

ADDITIONAL SKILLS

MANAGEMENT OF INFECTIOUS DISEASES – WOUND CARE

OTHER BASIC NURSING SKILLS DOCUMENTATION:

SETTINGS