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
    Fall Risk Assessment
    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.)
    Administration of Blood/Blood Products
    Insertion and Care of Straight & Foley Catheter
    Tube Feeding
    Standard Precautions
    Isolation Precautions
    Pain Management
    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
    PSYCHIATRIC & GENERAL SKILLS
    Admission
    Therapeutic Communication Skills
    Neurological Assessment
    Initial Treatment Plan
    Initial Nursing Assessment & Care Plan
    Nursing Diagnoses
    Nursing Reassessment & Care Planning Update
    Behavioristic charting
    Treatment/Goal Oriented charting
    Discharge Planning
    Patient Teaching
    Active Participation in Multi-Disciplinary Staffing
    Group Therapy Leader
    Multi-disciplinary Treatment Team Participation
    Participation in Milieu Therapy
    Assist Physician in Administration of Electroconvulsive Therapy
    Suicide Risk Assessment
    Suicide Precautions
    Psychiatric Emergency Response Team
    Rapid Tranquilization
    Telephonic Crisis Intervention
    Therapeutic Limit Setting
    Restraints-Application, Assessment & Reassessment of
    Seclusion
    Management of Drug/Alcohol Detox Symptoms
    Management of Assaultive Behavior
    Involuntary/Voluntary Commitment
    Crisis Prevention
    Vital Signs
    Knowledge of State Specific Regulations on Emergency
    O2 Therapy & Medication Delivery Systems
    Bag & Mask
    External CPAP
    Face Masks
    Inhalers
    Nasal Cannula
    Portable O2 Tank
    Oro-naso-pharynx Suctioning
    PSYCHIATRIC -Care of Patient With:
    Alcohol/Drug Abuse
    Alzheimer's/Dementia
    Anxiety Disorder
    Alcohol/Drug Dependency
    Bipolar Disorder
    Depressive Disorder
    Eating Disorder
    Schizophrenic Disorder
    Electroconvulsive Therapy
    Hallucinations
    History of Sexual/Physical Abuse
    Manic Behavior
    Organic Disorder
    Post Traumatic Stress Disorder (PTSD)
    Violent Behavior
    Seizure Disorder
    Suicidal Behavior
    MEDICATIONS
    Administration of Oral Psychotropic Medications
    Antabuse
    Anticonvulsants
    Antidepressants
    Antianxiety
    Antihypertensive
    Antipsychotics
    Cholinesterase Inhibitors ( Aracept/Namenda)
    Digoxin
    Heparin
    Insulin
    Lithium
    Methadone
    Management of Extrapyramidal Symptoms (EPS)
    Intramuscular
    Oral
    Rectal
    Sub-q
    Unit Dose
    Z-Technique
    SETTINGS
    Pediatric/Adolescent
    Adult
    Partial
    Inpatient
    Outpatient
    Eating Disorder Clinic
    Home Health
    Locked Unit
    Rehab Unit
    Substance Abuse/Rehabilitation