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
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Cardiac Monitoring/Interpretation
    PCA/Epidural pumps
    Standard Precautions
    Isolation Precautions
    Knowledge of "Do Not Use Abbreviations"
    Care Planning & Discharge Planning
    Patient/Family Education
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    CARDIOVASCULAR
    Cardiac Auscultation (Rate, Rhythm)
    Clinical Identification of Arrhythmias
    Fluid Overload/ CHF
    Peripheral Pulses/Circulation Checks
    PT/PTT/INR
    Holter Monitor
    Pacemaker/ AID
    Pre/ Post Cardiac Surgery
    Pre/ Post Vascular Surgery
    Medications:
    ACE Inhibitors
    Anti-arrhythmic
    Antibiotics
    Anticoagulants
    Antihypertensives
    Antiplatelet Medications
    Beta Blockers
    Calcium Channel Blockers
    Diuretics
    Digoxin (Lanoxin)
    Oral and Topical Nitrates
    Narcotics
    Potassium Supplements
    Statin Medications
    PULMONARY
    Asthma
    Auscultation of Lung Sounds/Rate & Work of Breathing
    Pulse Oximetry
    Administration of O2 via Nasal Cannula
    Apnea Monitor
    Chest Percussion
    Establishing an Airway
    Incentive Spirometry
    Orotracheal and Nasotracheal Suctioning
    Tracheostomy Care and Protocols, including Suctioning
    Nebulizer
    CPAP
    BiPAP
    Ventilator Management
    Chronic Obstructive Pulmonary Disease (COPD)
    Lung Cancer
    Primary Pulmonary Hypertension
    Pulmonary Fibrosis
    Pulmonary Emboli
    NEUROLOGICAL
    Neurological Signs/Level of Consciousness (LOC)
    Neuro-Motor/Sensory Functions
    Seizure Precautions
    Alzheimer's Disease
    Dementia
    Degenerative Neurological Disorders (ALS, MS, etc.)
    Cerebral Tumors
    Post-Cerebrovascular Accident
    Guillain-Barre Syndrome
    Hemiparesis
    Meningitis
    Parkinson's Disease
    Seizure Disorders
    Paraplegia/Quadriplegia
    Traumatic Brain Injury (TBI)
    ORTHOPEDICS
    Circulation/Skin Checks
    Assistive Devices
    TENS units
    Wheelchairs/Lift Equipment
    Amputation
    Arthritis
    Cast/Brace
    Fractures
    Traction
    Total hip/Knee/ Joint Replacement
    In home PT/INR
    GASTROINTESTINAL
    Nutritional Status
    Colostomy/Ileostomy Care
    Long-Term Feeding Tube
    Nasogastric (NG) Tube
    PEG/Gastrostomy Tube
    Drainage Devices/Tubes
    Tube Feeding
    Feeding Pumps
    Bowel Obstruction
    Fecal Incontinence
    Gastrointestinal Bleeding (G.I. Bleed)
    Post-Gastrointestinal Surgery
    Hepatitis
    Inflammatory Bowel Disease
    Liver Failure/ Transplant
    RENAL/GENITOURINARY
    Arterio-Venous Fistula/Shunt
    3-Way Bladder Catheter
    Foley Catheter Insertion/Maintenance
    Straight Catheterization
    Self-Catheterization
    Prostatectomy
    Peritoneal Dialysis
    Nephrostomy Tube
    Suprapubic Catheter
    Urostomy
    Hemodialysis (Receiving in an Out Pt. Clinic Setting)
    Home Hemodialysis
    Peritoneal Dialysis
    Post-Bladder Surgery
    Post-Prostate Surgery
    Shunts and Fistulas
    Urinary Incontinence
    ENDOCRINE/METABOLIC
    Diabetic Skin Assessment
    Hyper- and Hypoglycemia
    Glucometers
    Indwelling Insulin Pumps
    Diabetes
    Post Kidney Transplantation Surgery
    Thyroid Disease
    WOUND/SKIN CARE MANAGEMENT
    Assessment
    Braden Assessment Scale
    Surgical Wound Healing
    Skin Grafts
    Burns
    Pressure Ulcer Staging
    Care of Pressure Ulcers
    Dry and Wet to Dry Dressing Changes
    Positioning of Patients
    Special Mattresses and Positioning Devices
    Wound Care (Sterile)
    Wound Cultures
    Wound Irrigations
    Wound Vac
    ONCOLOGY
    Immune Status
    Symptoms Management
    Signs/Symptoms of Infection
    Reverse Isolation
    Radiation Therapy
    Leukemia/Lymphoma
    Post-Oncology Surgery
    Terminal Disease
    INFECTIOUS DISEASE
    Signs/Symptoms of Infection
    Isolation Precautions
    HIV Infection
    Tuberculosis
    MRSA/VRE
    C. Difficile
    PHLEBOTOMY/IV THERAPY
    Blood Draws from Lines
    Management of Long Term IV Catheters
    TPN/Hyperalimentation
    CVP Lines/Dressings
    PICC Lines/Dressings
    Tunneled Lines/Dressings
    Long-Term Lines/Dressings
    IV Pumps
    Other IV Pumps:
    PSYCHIATRY
    Monitoring Symptoms
    Compliance with Medications
    Cognitive Disorders
    Schizophrenia/Psychotic Disorders
    Substance-Related Disorders
    Mood Disorders (Anxiety/Depression, etc.)
    WOMEN'S HEALTH/MATERNAL-INFANT CARE
    Fetal Heart Tones
    Contractions
    Breast Feeding Teaching
    Pregnancy-Related Complications
    Post-Mastectomy
    Post-partum Mother/Baby Visit
    Newborn Care
    Bulb Suctioning
    Cord and Circumcision Care
    Phototherapy
    PEDIATRICS
    Growth and Development Stages
    Croup Tent
    Ventilator
    Trach
    Broncho Pulmonary Dysplasia
    Cystic Fibrosis
    Near Drowning
    Pre- and Post-Cardiac Surgery
    RSV
    Reye's Syndrome
    Pre- and Post-Spinal Surgery
    Sickle Cell Disease
    Spina Bifida
    PAIN MANAGEMENT
    Assessment
    Pain Scale
    Response to Pain Management Interventions
    Pharmacologic Pain Relief
    Non-pharmacologic Pain Relief Measures
    PCA Pump
    Epidural Catheter/Site Monitoring/Pump
    MEDICATIONS
    Alzheimer's Medications
    Antibiotics
    Anti HIV
    Antivirals
    Anti Parkinson's
    Bone Marrow Stimulants
    Bronchodilators
    Chemotherapy
    Low Molecular Weight Heparins ( Fragmin, Lovenox)
    Immunizations
    Insulin
    Inhalers
    Oral hypoglycemics
    Sedative/Hypnotics
    PALLIATIVE AND END-OF-LIFE CARE
    Family Support and Teaching
    Medication Protocols
    Symptom Management
    After Death Protocol and Management
    MISCELLANEOUS
    Safety Assessment
    Recognizing Failure to Thrive Across the Lifespan
    Advanced Directives
    CASE MANAGEMENT
    Experience as a Case Manager
    Case Load, usual number of patients cared for
    Supervision of Home Health Aides
    EXPERIENCE WITH
    Long-term/Short-term Disability
    Management of Complaints
    Medicare/Medicaid
    Pre-certifications
    Private Insurance
    Telephone Assessments
    Utilization Review
    Workman's Compensation
    DOCUMENTATION
    Diagnosis Coding (ICD Coding)
    Document Plan of Care (Form 485)
    OASIS Documentation
    Computer Charting