Proﬁciency Scale:

0 = No Experience / Observed Only

1 = Limited Experience / Rarely Done (<6 times/year)

2 = May Need Some Review / Occasionally Done (1 - 2 times/month)

3 = Experienced / Frequently Done (daily or weekly)

GENERAL SKILLS

0

1

2

3

Patient Head to Toe Assessment

Pain Management

Automated Med Dispensing Systems

Care Planning & Discharge Planning

Patient/Family Education

Electronic Documentation

Systems Used - Please List

Knowledge of Normal Serum Lab Values

Obtaining Cultures (Blood, Sputum, Swab)

Administration of Blood & Blood Products

Interpersonal Communication Skills

EXPERIENCED WITH

0

1

2

3

Research Process

Evidence-Based Nursing

Institutional Regulatory Board policies

Coordination of Study Treatments

Data Collection

Quantitative Studies

Data Analysis

Presentation of Research Study

Microsoft Office

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:

AGE OF PATIENTS CARED FOR

GENERAL SKILLS

EXPERIENCE IN RESEARCH

EXPERIENCED WITH