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:
    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
    SETTINGS
    Acute Care/ Hospital
    Rehabilitation - Acute
    Rehabilitation - Long Term
    Home Health
    Outpatient
    Day Treatment Centers
    Skilled Nursing Facility
    Physician's Office
    Early Intervention
    PATIENT POPULATIONS/DISORDERS
    Alzheimer's
    Amyotrophic Lateral Sclerosis ( ALS)
    Anoxia
    Aphasia
    Apraxia
    Autism
    Adult Mental Retardation ( Mild-Moderate)
    Adult Mental Retardation ( Severe-Profound)
    Pediatric Mental retardation ( Mild-Moderate)
    Pediatric Mental Retardation ( Severe-Profound)
    Brain Injury
    Cleft Palate
    Coma Stimulation
    Cognitive Impairment
    CVA
    Dysarthria
    Feeding Disorders
    Fluency
    Hearing Impairment
    Head Trauma
    Learning disabilities/Early Intervention
    Laryngectomy
    Muscular Dystrophy
    Multiple Sclerosis
    Parkinson's Disease
    Progressive Neurological Disease
    TIA
    Trachs
    Ventilator Dependent patients
    ASSESSMENT
    Aphasia Language Performance Scale
    Augmentative Devices
    Bedside Swallow Testing
    Boston
    Blue Dye Test
    Cervical Auscultation
    CADL ( Communication Ability for Daily Living)
    Detroit
    FEES ( Flexible Endoscopic Evaluation of Swallowing)
    Fiber optic Voice Evaluation
    Modified Barium Swallow Study
    Minnesota (Schuell)
    PICA ( Porch Index of Communication Ability)
    Pure Tone Screening
    Reading comprehension battery for aphasia
    Ross information processing assessment - geriatric
    Rossetti Infant-Toddler Language Scale
    Rehabilitation Institute of Chicago evaluation of communication
    Western Aphasia Battery
    TREATMENT
    Individual
    Co-Treatment
    Cognitive Training
    Community Re-Entry
    Computer
    Group
    Dysphagia management
    Feeding Equipment
    Memory Aids
    Safety Awareness
    Total Communication
    Vital Stimulation
    REGULATIONS/DOCUMENTATION
    FIMS
    Home Health Documentation
    Medi-Cal
    Medicare
    Omnibus budget reconciliation
    RUG levels