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)
    		•
    TYPE OF FACILITY EXPERIENCE
    Type of Facility Experience
    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
    Standard Precautions
    Isolation Precautions
    Pain Management
    Performing or participating in a Code Blue
    Care of Patient in Restraints
    Knowledge of Advance Directives
    Use of Sit to Stand
    Use of Hoyer Lift
    Automated Med Dispensing Systems
    Electronic Documentation
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Patient/Family Education
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    Other Automated Med Dispensing Systems:
    Other Electronic Documentation:
    MEDICATIONS-KNOWLEDGE AND USE OF
    Pouring From Stock Medications
    Narcotic Administration
    IV Push/Drip Medications
    Antibiotics
    Oral
    Topical
    Otic
    Rectal
    Vaginal
    Ophthalmic
    Continuous Subcutaneous Infusion Pumps
    Total Parenteral Nutrition (TPN)
    Peripheral Parenteral Nutrition
    Patient Controlled Analgesia (PCA)
    Administering Medications through G/GJ/NJ Tubes
    PHLEBOTOMY / IV THERAPY
    Blood Draw-Peripheral
    Mixing IVs
    Regulating IVs
    IV Infusion Pumps
    Blood/Blood Product Administration
    IV Pumps
    Other IV Pumps:
    CARDIAC GENERAL
    Recognizing Basic & Life-Threatening Dysrhythmias
    Congestive Heart Failure
    CARDIAC-Care of patient with:
    Pulse Checks
    Use of Doppler
    Cardiac Monitors
    Obtaining EKGs - 12 Lead
    Use of Automatic BP Cuff (ie Dinamap)
    KNOWLEDGE AND USE OF
    Nitrates (Oral, Topical)
    Antiarrythmics (Oral)
    Antihypertensives (Oral)
    RESPIRATORY GENERAL
    Emphysema
    COPD
    Asthma Exacerbation
    Tracheostomy
    Pneumonia
    Pre/Post Thoracic Surgery
    Chest Tubes
    RESPIRATORY-Care of patient with:
    Collection of Sputum Specimen
    O2 Cannulas/Masks
    Non-rebreather Mask
    Nebulizer Set-up/Use
    Incentive Spirometry
    Chest PT
    Suctioning (Oral/Nasotracheal)
    Suctioning (Tracheostomy Tube)
    Ventilator Patient (Mouth Care, Suctioning, Ambu bag)
    KNOWLEDGE AND USE OF
    Bronchodilators (Oral, IV, Inhaler)
    Steroids
    NEURO GENERAL
    Spinal Cord Injury - Acute
    Spinal Cord Injury - Long Term
    CVA Stroke
    Neuromuscular Disease
    Alzheimer Disease
    Wandering
    Hallucinations
    Anxiousness
    Agitation
    Reality Orientation
    NEURO-Care of patient with:
    Assessing Levels of Consciousness
    Pupil Checks
    Seizure Precautions
    Stroke Precautions
    Swallow Precautions
    Lumbar Puncture
    Use of Hyper/Hypothermia Blanket
    SENSORY DEFICITS-Care of patient with:
    Dentures
    Hearing Aid Devices
    Care of Patients with Hearing Loss
    Prosthetic Eye
    Contact Lens Care
    Cataracts
    Blindness
    Macular Degeneration
    KNOWLEDGE AND USE OF
    Anticonvulsant
    Sedative
    GI GENERAL
    Nasogastric Tubes (i.e. Salem Sump, Levine)
    Nasointestinal Tubes (i.e. Cantor, Miller-Abbot)
    Jejunostomy, Gastrostomy, Cecostomy Tubes
    Colostomy, Ileostomy
    Administration of Tube Feedings via Flexible Tubes
    By Gravity Infusion
    By Feeding Pump
    GASTROINTESTINAL-Care of patient with:
    Collection of Stool Specimens
    Bowel Preparation and Cleansing Procedures
    Bowel Disimpaction
    Bowel Retraining
    Sitz Bath Treatments
    Inserting and Checking Placement/Patency NG Tubes
    ENDOCRINE GENERAL
    Diabetes
    Hyper/hypoglycemia
    ENDOCRINE-Care of patient with:
    Blood Glucose Monitoring
    Performing Fingersticks
    Use of Blood Glucose Meter Device
    Use of Visual Blood Glucose Strips
    KNOWLEDGE AND USE OF
    Insulin
    Single Type
    Mixed Insulins
    Insulin Infusion
    RENAL/GU GENERAL
    Insertion of Catheter-Female
    Insertion of Catheter - Male
    Insertion of Suprapubic Catheter
    Applications of Condom Catheter
    Ability to Insert a Straight Catheter or Foley Catheter
    Collection of Sterile Urine Specimen
    RENAL/GU-Care of patient with:
    Incontinence
    Urinary Retention
    UTI
    Bladder Retraining
    Urinary Diversion
    Bladder Irrigation (Continuous and Intermittent)
    Peritoneal Dialysis
    Manual
    Automatic Cycler Machine
    ORTHOPEDIC GENERAL
    Total Joint Replacement
    Rheumatic/Arthritic Disease
    Amputation
    Fracture
    ORTHOPEDIC-Care of patient with:
    Cast Care
    CMS Checks
    Traction - Skin
    Traction - Skeletal
    Range of Motion
    Use of Assistive Devices
    Applications of Splints of Extremities
    Continuous Passive Motion Machine (CPM)
    Transfer Techniques
    Use of a Sliding Board
    Gait Training/Retraining
    Application of Prosthetic Devices
    Application of Orthotic Devices
    WOUND/SKIN-Care of patient with:
    Pressure Sores
    Leg Ulcers
    Burns
    WOUND/SKIN GENERAL
    Acute Dressing Changes
    Wound Care
    Irrigations
    Identifying Common Skin Problems
    Recognizing Normal Skin Changes
    Use of Special Pressure Relief Devices
    Pressure Relief Mattress/Seat Cushion
    ADDITIONAL SKILLS-Care of patient with:
    Hemovacs
    Jackson-Pratt Drains
    Penrose Drains
    T-Tubes