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 (1 month to 1 year)
    Toddler (1 year to 3 years)
    Preschooler (3 years to 5 years)
    School Age Child (5 years to 12 years)
    Adolescents (12 years to 18 years)
    Young Adults (18 years to 39 years)
    Middle Adults (39 years to 64 years)
    Older Adults (64 years to 79 years)
    Elderly Adults (over 79+ years)
    GENERAL NURSING SKILLS
    Standard Precautions
    Isolation Precautions
    Adult Respiratory/Cardiac Arrest
    Crash Carts
    Defibrillators
    Care of Patient in Restraints
    Automated Med Dispensing Systems
    Patient/Family Education
    Electronic Documentation
    Systems Used - Please List
    Patient Head to Toe Assessment
    Wound Care
    Care Planning & Discharge Planning
    Consult with Physicians & Ancillary Health Staff
    MEDICATIONS - Knowledge and use of
    Pouring From Stock Medications
    Narcotic Administration
    IV Push/Drip Medications
    Antibiotics
    Continuous Subcutaneous Infusion Pumps
    Total Parenteral Nutrition (TPN)
    Peripheral Parenteral Nutrition
    Patient Controlled Analgesia (PCA)
    Knowledge of "Do Not Use Abbreviations"
    SKILLED ENVIRONMENTS
    Acute Care/ Hospital
    Managed Care
    SNF/ Long Term Care
    Home Health
    Outpatient
    GENERAL LEADERSHIP SKILLS
    Written Communication Skills
    Verbal Communication Skills
    Basic Negotiation Skills
    Job Related Computer Skills
    Ability to Prioritize
    Ability to Properly Maintain Records
    Ability to Work Effectively in All Situations
    Ability to Gather Data, Compile Information and Prepare Reports
    Knowledge of Medical Billing Procedures
    Community and Relationship Management
    Regulations and guidelines of Long Term Care
    Conflict Resolution
    Quality Audits
    Knowledgeable of research design and principles
    KNOWLEDGE OF HEALTHCARE ENVIRONMENT
    HIPAA and Patient Rights
    Staff Roles and Responsibilities
    Organizational Policy and Risk Management
    Quality Improvement
    Financial Management
    Billing and Reimbursements
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    Knowledge of Oasis
    Knowledge of CMS
    Managing Nursing Competency Programs
    Providing Clinical Training and Education
    Ensuring Quality Outcomes
    Developing Policies to Mitigate Risk
    Implementing Protocols to Keep up with Current Practice
    Provide Clinical Guidance to Ensure Optimal Quality of Care in the Region
    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: