Personal Information

*Please fill the email ID correctly for successful submission

Legends

1 = Theory – No Experience

2 = Minimal Experience (0-12 Months)

3 = Experienced/Competent (Greater than 12 Months)

4 = Able to Teach/ Supervise

Respiratory

Assessment of Breath Sounds

Establishing an Airway

Ambuing Techniques

Oxygen Therapy

Nasal Cannula Prongs

Ventimask

Rebreather/ Non-Rebreather Mask

Pulse Oxymeter

Car diac

Assessment of Heart Sounds

Cardiac Arrest/CPR

Administration of Emergency Medications

Use of Defibrillator

Use of Cardioversion

Care of the Patient With

CVA/TIA

Overdose

Head Injury/Trauma

Spinal Cord Injury

Paraplegia

Quadriplegia

Neuro Surgery

Cranial Hemorrhage

AV-Shunt Placement

Multiple Sclerosis

Care of the Patient With

Appendicitis

GI Bleed

Pancreatitis

Bowel Obstruction

Paralytic Ileus

Liver Failure

Hepatitis

Laparoscopic Abd Procedures

Open Abd Procedures

Care of the Patient With

Chronic/Acute Renal Failure

Renal Calculi

Renal Trauma

Nephrectomy

TURP

Radical Prostatectomy

Hemodialysis

Peritoneal Dialysis

Orthopedic

Amputation

Arthroscopic Surgery

Total Joint Replacement

Cast Care

Orthopedic Trauma

Urinary Tract Infection

Vulvovaginitis

Hydrocele

Gonococcal Infections

Prostatitis

Hypospadias

Benign Prostatic Hypertrophy

Skeletal Traction

Bucks Traction

Pin Site Care

Laminectomy

Passive ROM Exercises

Other

Accuchecks

Burn Patients

Diabetic Teaching

Isolation Techniques

Chemotherapy

Oncology

Patient Teaching

Nutritional Teaching

Knowledge of Normal Lab Values

Simple Dressing Changes

Complex Dressing Changes

Skin Assessment

Fall Assessment

Soft Restraints

Posey Restraints

Informed Consent

Telemetry

Obtaining 12 Lead EKGs

Interpretation of EKG

Arrhythmia Interpretation

Monitor Set-Up

Lead Placement

Pacemakers

A Line (Set-Up and D/C)

Sheath Removal-Femoral

Respiratory

Chest Tubes

Obtaining Blood Sample for ABG

Arterial Puncture

MEDICATIONS

Amiodarone

Atropine

Bretylium

Cardizem

Digoxin

Dopamine

Epinephrine

Heparin

Inderal

Lidocaine

Morphine

Vasopressin

Nipride

Nitroglycerin

Quinidine

Sodium Bircarbonate

Verapamil

Certification(s)	Expiration Date(s)
BLS
ACLS
NRP
PALS
OTHER
OTHER 2

Licensure(s) Number(s)	State(s)	Expiration Date(s)

AREAS OF EXPERTISE	MONTHS	YEARS
Management Duties
Charge Duties

^*Please enter information you feel is important or necessary to give further explanation for information provided above:

I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.

Personal Information

Legends

SKILLS - MEDICATION ADMINI STRATION

Respiratory

Sputum Collections

Car diac

Neurology

Care of the Patient With

Gastrointestinal

Care of the Patient With

Renal

Care of the Patient With

Vascular

Orthopedic

Gynecology

Other

Care of the Patient With

Telemetry

Care of Patient with

Respiratory

Vascular

MEDICATIONS