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:
    IV Pumps
    Other IV Pumps:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Blood draws from PICC line, Central line
    PCA/Epidural pumps
    Administration of Blood/Blood Products
    Occluded ports or catheters
    NG tube insertion
    Enterostomy/ostomy care
    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
    HOSPICE CARE
    Admit and Initial Assessment
    Infection control
    Universal precautions
    Isolation
    Reverse Isolation
    Minimize fall risks
    Restraints
    Lift/transfer devices
    Interpretation and communication of lab values
    Non-pharmacologic interventions
    Blood Glucose monitoring
    PLAN OF CARE
    Advanced directives
    Set Goals with Pt/family
    Resources for Pt/family
    Pt teaching self care
    Quality of life issues
    Death and dying counseling
    Stages of grieving
    Pt care after death
    Facilitate family/cultural rituals/rites
    Spiritual Care
    Pronouncement of death
    Coordinate mortuary services
    COMPLIANCE
    Scope and frequency of services
    Medicare/State regulations for hospice
    Document progression of decline
    DME authorization and documentation of need/order
    OASIS-C
    PAIN MANAGEMENT
    Pain assessment/management
    Moderate sedation
    Administration of narcotics/sedatives
    PAINAD Scale for nonverbal patients
    Continuous narcotic infusion
    Transdermal agents
    TENS units
    Alternative therapies
    Titration of opioids
    Family management of medications
    Disposal of Medications
    Equianalgesic Conversion Formula
    WOUND CARE
    Speciality beds
    Prevention of pressure ulcers
    Staging and care of pressure ulcers
    Wound care
    Use of Woundvac
    Positioning Techniques
    Educate Pt/Family on positioning/shearing
    MEDICATIONS
    Bar coding for medication administration
    Insulin administration
    Anticoagulation therapy
    Medication reconciliation
    Oral Medication
    Topical Medication
    Opthalmic/Otic Medication
    Rectal/vaginal medication
    IM/SQ medication
    IV push medications
    IVPB medications
    Continuous infusions
    PPN
    TPN
    J-tube/G-tube feedings
    PHYSICAL ASSESSMENT
    Cardiovascular assessment
    Respiratory assessment
    Use of oxygen
    Use of Incentive Spirometer
    Nasal cannula/face mask
    Nebulizers
    Use of ambu bag
    Pulse oximetry
    Oral and nasotracheal suctioning
    Tracheostomy care
    Neuro assessment
    Sleep assessment
    Seizure precautions
    Gastrointestional assessment
    Nutrition assessment
    NG tube insertion/management
    Feeding tube insertion/management
    PEG/gastrostomy/ jejunostomy management
    Ostomy care
    Foley catheters
    Suprapublic tube
    Nephrostomy
    Shunts/fistulas
    PEDIATRICS
    Developmentally appropriate assessment
    parent/sibling support
    pediatric support team collaboration
    Fatigue
    Constipation
    Nausea/vomiting
    CERTIFICATIONS
    CHPN
    ACHPN
    CHPPN