Proﬁciency Scale:

1 – No Experience

2 – Need Training

3 – Able to perform with supervision

4 – Able to perform independently"

CARDIOVASCULAR Care of the Patient with:

1

2

3

4

External Pacer

Chest Pain/ACS

Arrhythmias

CHF

AED

Cardiac Arrest/CPR

Medications

Nitroglycerin

Morphine

Heparin

ALS (Epinephrine, Atropine, Anti-Arrhythmics)

PULMONARY Care of the Patient with:

1

2

3

4

Aspiration

Asthma/Reactive Airway Disease

COPD

Pneumonia

Pulmonary Edema

Pulmonary Embolism

Medications

Bronchodilators

Steroids

Diuretics

NEUROLOGICAL Care of the Patient with:

1

2

3

4

Head Injury

Meningitis

Migraine

Seizures

TIA/Stroke

Medications

Imitrex (Sumatriptan Succinate)

Phenobarbitol

Dilantin (Phenytoin)

Depakote

Analgesics

ORTHOPEDICS Care of the Patient with:

1

2

3

4

Cast/Splint

Dislocation

External Appliance

Sprain/Fracture

Medications

Analgesia/Sedation

GASTROINTESTINAL Care of the Patient with:

1

2

3

4

Colostomy

Constipation/Impaction

Diarrhea

G-Tube (Reinsertion/Replacement)

Nausea/Vomiting

Medications

Ipecac

Charcoal

Antiemetics

Antispasmodics

RENAL/GENITOURINARY Care of the Patient with:

1

2

3

4

Pyelonephritis/UTI

Obstruction

Renal Calculi

Renal Trauma

Testicular Torsion

Priapism

Medications

Antibiotics

EENT

1

2

3

4

Assessment

Visual Acuity

Foreign Body

Enlarged Tonsils

Ear Irrigation/Removal Foreign Body

Eye Injury/Foreign Body/Detached Retina

Assist with Removal of Nasal Foreign Body

Epistaxis

Set Up/Assist Cautery

Set Up Slit Lamp

Silver Nitrate

Liquid Cocaine

Anti-Hypertensives

INFECTIOUS DISEASE Care of the Patient with:

1

2

3

4

Communicable Disease

Infectious Disease

Immunosuppression/Neutropenia

Medications

Antibiotics

Antivirals

PAIN MANAGEMENT

1

2

3

4

Assessment of Pain Level/Use of Pain Scale

Assessment of Response to Pain Management Interventions

Monitoring of Patients after Pain Medication

Comfort Care

Moderate Sedation

PSYCHIATRIC Care of the Patient with:

1

2

3

4

Drug OD

ETOH OD

Depression/Anxiety

Restraints

Suicide Risk

Medications

Antipsychotics/Antidepressants

Reversal Agents

WOMEN'S HEALTH Care of the Patient with:

1

2

3

4

Ectopic Pregnancy

Hemorrhage

Pelvic Inflammatory Disease

Placenta Abruptio/Previa

Precipitous Delivery

Pregnancy-Induced Hypertension

Spontaneous Abortion

PEDIATRICS Care of the Pediatric Patient with:

1

2

3

4

Abdominal Pain

Aspiration

Asthma/Reactive Airway Disease

Burns

Dehydration

Epiglottitis

Fever

Foreign Object

Fracture

Head Injury

Hypo/Hyperglycemia

Hypo/Hyperthermia

Lacerations

Near Drowning

Nursemaid's Elbow

Age Speciﬁc Competencies

1

2

3

4

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)

MISCELLANEOUS Care of the Patient with:

1

2

3

4

Bites

Hazardous Materials Exposure

Victims of Acts of Violence

My experience is primarily in the following settings

Adults	Year/No of Days
Physician's Oﬃce
Clinic
Urgent Care
Emergency Dept - Yrs:

Pediatrics	Year/No of Days
Physician's Oﬃce
Clinic
Urgent Care
Emergency Dept - Yrs:

Certifications	Expiration Date:
BLS
ACLS
PALS
Other: Specify

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:

CARDIOVASCULAR

CARDIOVASCULAR Care of the Patient with:

PULMONARY

PULMONARY Care of the Patient with:

NEUROLOGICAL

NEUROLOGICAL Care of the Patient with:

ORTHOPEDICS

ORTHOPEDICS Care of the Patient with:

GASTROINTESTINAL

GASTROINTESTINAL Care of the Patient with:

RENAL/GENITOURINARY

RENAL/GENITOURINARY Care of the Patient with:

ENDOCRINE/METABOLIC

ENDOCRINE/METABOLIC Care of the Patient with:

EENT

INFECTIOUS DISEASE

INFECTIOUS DISEASE Care of the Patient with:

WOUND MANAGEMENT

PAIN MANAGEMENT

PSYCHIATRIC

PSYCHIATRIC Care of the Patient with:

WOMEN'S HEALTH

WOMEN'S HEALTH Care of the Patient with:

PEDIATRICS

PEDIATRICS Care of the Pediatric Patient with:

Medications (Others in System Speciﬁc Areas)

Age Speciﬁc Competencies

MISCELLANEOUS

MISCELLANEOUS Care of the Patient with:

My experience is primarily in the following settings