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
    Electronic Documentation
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    Universal Precautions
    Working with patients in isolation
    Working with patients in restraints
    Patient/Family teaching
    Patient Identification
    Specialty beds
    End of life care/palliative 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
    ENVIRONMENTS
    Acute Care/ Hospital
    Durable Medical Equipment ( DME)
    Managed Care
    SNF/ Long Term Care
    Home Health
    Hospice
    Outpatient
    Physician Office
    MANAGEMENT
    Understanding of health care economics and health care policies as it applies to delivery of patient care
    Concepts of capital budgeting
    Department/unit budgeting
    Recruitment techniques
    Interviewing techniques
    Labor Laws pertaining to hiring
    Orientation of new employees
    Knowledge of quality improvement/performance improvement tools
    Particpating, leading and supporting during CODE BLUE
    Patient Safety
    Workplace safety
    Promotion of interdepartmental communication
    Performance management
    Staff Development
    Coaching and mentoring
    Project management
    Business development
    Developing strategic plans
    Developing operational plans
    Cultural competence
    Personal growth and development
    Ethical behavior and practice
    Professional association involvement
    Conflict Management
    Team dynamics
    Mediation/coaching
    Joint Commission Standards
    OSHA Standards
    Risk Management/Service Utilization
    Local Department of Health
    State Department of Health
    Sitter Services
    SPECIALTY EXPERIENCE
    ER
    ICU
    MICU
    SICU
    TICU
    PICU
    NICU
    OR
    Med-surg
    Post-partum
    High Risk Perinatal
    Telemetry
    PACU
    Oncology
    Pediactrics
    Psychiatry
    Dialysis
    Coronary/Cardiac Care Unit
    Palliative Care or Hospice
    Rehabilitation
    Step-down Unit
    Orthopedics
    Pulmonary
    GI
    Geriatric
    Neurology
    Other: