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Skills Checklist Form

Items in red are REQUIRED fields.

Personal Information:
First Name:        Middle Initial:
Last Name:
Address:
City:
State:        ZIP:
Phone:
E-mail Address:
Years of Experience:

Directions for completing Skills Checklist:
The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar. Use the following KEY as a guideline:
A) Theory Only/No Experience - Didactic instruction only, no hands-on experience.
B) Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months.
C) Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.
D) Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.
A. CARDIOVASCULAR:
1. Assessment:  A     B     C     D
      a. Auscultation (rate/rhythm)         
      b. Blood Pressure (non-invasive)         
      c. Doppler         
      d. Heart sounds/murmurs         
      e. Pulses/circulation checks         
2. Equipment/Procedures:  A     B     C     D
      a. Telemetry  
          (I) Basic arrhythmia interpretation         
          (II) Lead placement         
      b. Pacemakers  
          (I) Permanent         
          (II) Temporary         
3. Care of the patient with:  A     B     C     D
      a. Abdominal aortic bypass         
      b. Aneurysm         
      c. Angina         
      d. Cardiac arrest         
      e. Cardiomyopathy         
      f. Cartoid endartarectomy         
      g. Congestive heart failure (CHF)         
      h. Femoral-popliteal bypass/ Aorta-Femoral bypass         
      i. Myocarditis         
      j. Post acute MI (24 - 48 hrs)         
      k. Post angioplasty         
      l. Post cardiac cath         
      m. Post cardiac surgery - bypass grafts/ valvular/ replacement         
      n. Thrombophlebitis         
4. Medications:  A     B     C     D
      a. Heparin drip         
      b. Oral anticoagulants         
      c. Oral & IVP antihypertensives         
      d. Oral & topical nitrates         
B. PULMONARY:
1. Assessment:  A     B     C     D
      a. Chest/Lungs: inspection, palpitation, percussion, auscultation         
      b. Breathing patterns/rate/SOB inspiration         
      c. Cough/secretions/hemoptysis         
      d. Pains - chest         
      e. Skin - color         
2. Interpretation of lab results:  A     B     C     D
      a. Blood chemistry         
      b. Blood gases         
3. Equipment & procedures:  A     B     C     D
      a. Airway management devices/suctioning  
          (I) Endotracheal tube/suctioning         
          (II) Nasal airway/suctioning         
          (III) Oropharylgeal/suctioning         
          (IV) Sputum specimen collection         
          (V) Tracheostomy/suctioning         
      b. Assist with intubation         
      c. Assist with thoracentesis         
      d. Care of the patient with a chest tube  
          (I) Assist with setup and insertion         
          (II) Measuring & emptying         
          (III) Removal         
      e. Chest physiotherapy         
      f. Incentive spirometry         
      g. O2 therapy & medication delivery systems  
          (I) Bag & mask         
          (II) External CPAP         
          (III) Face masks         
          (IV) Inhalers         
          (V) Nasal cannula         
          (VI) Portable O2 tank         
          (VII) Trach collar         
      h. Oximetry         
4. Care of the patient with:  A     B     C     D
      a. Bronchoscopy         
      b. COPD         
      c. Fresh tracheostomy         
      d. Lobectomy         
      e. Pneumonectomy         
      f. Pneumonia         
      g. Pulmonary embolism         
C. NEUROLOGICAL:
1. Assessment:  A     B     C     D
      a. Mental status/LOC/Glasgow Coma Score         
      b. Motor movement/ROM/Strength coordination         
2. Equipment & Procedures:  A     B     C     D
      a. Assist with lumbar puncture         
      b. Use of hyper/hypothermia blanket         
3. Care of the patient with:  A     B     C     D
      a. Closed head injury         
      b. Coma         
      c. CVA         
      d. DTs         
      e. Encephalitis         
      f. Meningitis         
      g. Neuromuscular disease         
      h. Post craniotomy         
      i. Seizures         
      j. Spinal cord injury         
4. Medications:  A     B     C     D
      a. Nonopiod analgesic         
      b. Opiods         
      c. Antidepressants         
      d. Anticonvulsants         
D. ORTHOPEDICS:
1. Assessment:  A     B     C     D
      a. Joints - Inspection/Palpation         
      b. Posture         
      c. Mobility/gait/positioning/transfers         
      d. Skin - Inspection/Palpation         
      e. Circulation Checks         
2. Equipment/Procedures:  A     B     C     D
      a. Splints: Ace wraps/Immobilizers - Knee, cervical, shoulder, wrist         
      b. K-pad         
      c. Crutches axillary, forearm, cane         
      d. Prosthetics         
      e. Traction: skin/skeletal, Bryant's, Buck's, halo, tongs         
3. Care of the patient with:  A     B     C     D
      a. Amputation         
      b. Arthoscopic surgery         
      c. Cast         
      d. Osteoporosis         
      e. Pinned fractures         
      f. Rheumatic/Arthritic disease         
      g. Total knee/total hip replacement         
E. GASTROINTESTINAL:
1. Assessment:  A     B     C     D
      a. Abdominal/bowel sounds/inspection         
      b. Nutrition - diet/fluid Balance height/weight         
2. Equipment/Procedures:  A     B     C     D
      a. Measuring abdominal girth         
      b. Throat swab         
      c. Guaiac test         
      d. Lavage         
      e. Tube feeding/gavage (placement): NG, GT, JT         
      f. Feeding pumps         
      g. T-tubes, drains         
      h. Vacuum/suction         
3. Care of the patient with:  A     B     C     D
      a. Bowel obstruction         
      b. Colostomy/ileostomy         
      c. GI bleeding - gastritis, peptical ulcer         
      d. GI surgery         
      e. Hepatitis         
      f. Inflammatory bowel disease         
      g. Liver failure         
      h. Paralytic ileus, colitis, appendicitis         
F. RENAL / GENITOURINARY:
1. Assessment:  A     B     C     D
      a. Vital signs - BP, HR, RR, Temp         
      b. Intake/output         
      c. Weight (recent change)         
      d. Nutrition/fluid balance         
      e. Edema/skin lesions/distention         
      f. Urination - dysuria, discharge, frequency, incontinence, urgency         
2. Equipment/Procedures:  A     B     C     D
      a. Urinalysis  
          (I) Color, appearance, odor         
          (II) Dipstick - blood, ketones, PH, etc.         
          (III) Specific gravity         
      b. Laboratory findings  
          (I) CBC         
          (II) Comprehensive metabolic panel         
          (III) 24 degree urine          ">
          (IV) Culture(s)         
      c. Foley catheterization/straight cath         
      d. Suprapubic catheter         
      e. 3-way catheter         
      f. Bladder irrigations - intermittent, continuous         
      g. Dialysis accesses  
          (I) A-V Fistula         
          (II) Double lumen catheters         
          (III) Peritoneal catheters         
3. Care of the patient with:  A     B     C     D
      a. Hemodialysis         
      b. Nephrectomy         
      c. Peritoneal dialysis         
      d. Renal failure         
      e. Renal transplant         
      f. TURP         
      g. Urinary diversion/ileal conduit/nephrostomy         
      h. Urinary tract infection         
G. ENDOCRINE / METABOLIC:
1. Assessment:  A     B     C     D
      a. S/S diabetic coma         
      b. S/S insulin reaction         
2. Equipment/Procedures:  A     B     C     D
      a. Glucometers  
          (I) Type:  / System:         
                Type:  / System:         
      b. Insulin pumps  
          (I) Type:  / System:         
                Type:  / System:         
      c. Performing finger stick         
      d. Visual blood glucose sticks         
3. Care of the patient with:  A     B     C     D
      a. Diabetes mellitus         
      b. Disorders of Adrenal gland (addison's disease)         
      c. Disorders of Pituitary gland (Diabetes insipidus)         
      d. Hyperthyroidism         
      e. Hypothyroidism         
      f. Thyroidectomy         
4. Medications:  A     B     C     D
      a. Insulins         
      b. Antithyperglycemics         
      c. Steroids - Adrenocorticosteroids         
      d. Hormone preparations         
H. WOUND MANAGEMENT:
1. Assessment:  A     B     C     D
      a. Skin for impending breakdown         
      b. Stasis ulcers         
      c. Surgical wound healing         
2. Equipment/Procedures:  A     B     C     D
      a. Air fluidized, low airloss beds         
      b. Sterile dressing changes         
      c. Wound care/irrigations         
3. Care of the patient with:  A     B     C     D
      a. Burns         
      b. Pressure sores         
      c. Staged decubitis ulcers         
      d. Surgical wounds with drains         
      e. Traumatic wounds         
I. ON