Long Term 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. CARDIAC:  A     B     C     D
   1. Use of cardiac monitors         
   2. Assessment of heart sounds         
   3. Cardiac Arrest         
   4. CPR         
   5. Care of patients with CHF         
   6. Atropine administration         
   7. Digoxin administration         
   8. Dopamine administration         
   9. Inderal administration         
   10. Lidocaine administration         


B. GENITOURINARY:  A     B     C     D
   1. Fluid balance         
   2. Foley catheter insertion         
   3. Ileostemy         
   4. GU Irrigations         
   5. Nephrostomy tube         


C. ENDOCRINE:  A     B     C     D
   1. Blood Glucose checks         
   2. Insulin Administration         
   3. Care of patients with Diabetes         


D. GASTROINTESTINAL:  A     B     C     D
   1. NG tube care and feedings         
   2. Gastrostomy tube care and feedings         
   3. Colostomy care         
   4. Assessment of bowel sounds         


E. LEADERSHIP/PATIENT CARE:  A     B     C     D
   1. Taking charge         
   2. Admission procedures         
   3. Discharge procedures         
   4. Patient education         
   5. Patient care plans         


F. MEDICATIONS/IV THERAPY:  A     B     C     D
   1. Medication calculation         
   2. Reconstitution         
   3. Oral administration         
   4. Eye administration         
   5. IM administration         
   6. SQ administration         
   7. Rectal administration         
   8. Starting IVs         
   9. IV medication administration         
   10. Central line care         


G. NEUROLOGY:  A     B     C     D
   1. Assessment of neurological status         
   2. Seizure precautions         
   3. Care of patient with a CVA         
   4. Care of patient with Alzheimer's         
   5. Care of patients with spinal cord injury         
   6. Decadron administration         
   7. Dilantin administration         
   8. Phenobarbital administration         
   9. Valium administration         


H. ORTHO/SKIN:  A     B     C     D
   1. Assessment of skin         
   2. Wound care and treatments         
   3. Use of special pressure relief devices         
   4. Care of patient with total hip replacement         
   5. Care of patient with total knee replacement         
   6. Crutch walking         


I. RESPIRATORY:  A     B     C     D
   1. Pulse oximetry         
   2. Oxygen administration via nasal cannuia         
   3. Oxygen administration via face mask         
   4. Principles of chest percussion         
   5. Care of patients with ventilator         
   6. DCare of patients with COPD         
   7. Care of patients with ARDS         
   8. Care of patients with a tracheotomy         

The information I have given is true and accurate to the best of my knowledge. I hereby authorize Professional Nursing Service to release my Long Term Skills Checklist to Client facilities of PNS in relation to consideration of employment as a Traveler with those facilities.

Yes, I agree and consent to the statement above         Date:


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