Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 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)
    		•
    AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Care of Patient in Restraints
    Electronic Documentation
    Other Electronic Documentation:
    Documentation of ADLs
    Universal Precautions
    Measuring and Documenting Intake and Output
    Standing Scale Patient Weight
    Bed Scale Patient Weight
    Charting
    Bed Making Occupied
    Bed Making Unoccupied
    Code Cart
    Point of Care Blood Glucose Monitoring
    Bed Rails (Putting Up, Down, How to Use)
    Bed Alarm
    Vital Signs
    Hand Hygiene
    Coughing and Deep Breathing
    Dietary Needs
    Urine Specimen Collection-Routine
    Urine Specimen Collection-Clean Catch
    Urine Specimen Collection-12 and 24 Hour
    Stool Specimen Collection
    Reporting Change in Patient Condition
    Dismissal of Patient
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    Donning and doffing PPE
    Use of Sit to Stand
    Use of Hoyer Lift
    Use of Gait Belt
    Assisting with Patient Transfer (bed to chair or wheelchair and from chair or wheelcahir to bed)
    Activities of Daily Living
    Assisting With Ambulation
    Assisting With Toileting
    Bathing of Patient (Shower, Bed Bath)
    Bathing Patient with PICC Line
    Perineal Care
    Back Care
    Positioning of Patient
    Range of Motion Exercises
    Foley Care and Measuring of Output
    Oral Hygiene
    Denture Care
    Skin Care
    WOUND/SKIN-Care of Patient with:
    Dressing Changes
    Pressure Relief Mattresses
    Decubitus Ulcers
    Leg Ulcers
    ADDITIONAL SKILLS-Care of Patient With
    Hemovacs
    Jackson-Pratt Drains
    Penrose Drains
    Surgical Wound Irrigations & Dressings
    Ventilators
    Oxygen
    Suicidal Ideation
    Dementia/Alzheimers
    Limited Mobility
    INFECTIOUS DISEASE - Care of the patient with
    COVID
    HIV
    MRSA
    CRE
    VRE
    C. Difficile
    Hepatitis
    Influenza
    Isolation Precautions
    Shingles
    Scabies
    WORK SETTINGS
    Acute Care/ Hospital
    Managed Care
    SNF/ Long Term Care/Assisted Living
    Home Health
    Outpatient