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)
  • TYPE OF FACILITY EXPERIENCE
    TYPE OF FACILITY EXPERIENCE
    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.)
    Cardiac Monitoring/Interpretation
    PCA/Epidural pumps
    Titration of drips
    Administration of Blood/Blood Products
    Dressing Changes
    Knowledge of Normal Serum Lab Values
    Obtaining Cultures (Blood, Sputum, Swab, Urine)
    Care of Patient with Burns
    Care of Patient with HIV/AIDS
    Hyperbaric Oxygenation
    Suicide Precautions
    Post Mortem Cares
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    MEDICATION KNOWLEDGE AND USE OF
    Moderate/Conscious Sedation & Reversal Agents
    Calculate mcg/min and mcg/kg/min
    Antiemetics
    Amiodarone
    Cardizem
    Decadron
    Dilantin
    Magnesium Sulfate
    Phenobarbital
    Steroids
    Valium
    Atropine
    Diuretics
    Digoxin
    Dopamine
    Dobutrex
    Heparin Drip (Precautions & Maintenance)
    Inderal
    Inocor
    Isuprel
    Lidocaine
    Neosynephrine/Nipride
    Nitroglycerin
    Pronestyl
    Morphine
    Thrombolytic Agents
    Magnesium Sulfate
    Prep/Titration of Emergency Drugs
    NEURO GENERAL SKILLS
    Assessment of Neuro Signs
    Glascow Coma Scale
    Seizure Precautions
    Assist with Lumbar Puncture
    Halo Traction
    NEURO-Care of Patient With:
    CVA
    Seizure Activity
    Overdose
    Neuro/Head Injury/Trauma
    Pre/Post Neuro Surgery
    Cranial Hemorrhage
    Multiple Sclerosis
    Post-Op AV-Shunt
    CARDIAC GENERAL SKILLS
    Auscultation of Cardiac Sounds
    Dopplers
    Tele/EKG Interpretation
    Defibrillation/Cardioversion
    Permanent Pacemaker
    Temporary Pacemaker
    AICD
    Art-Line (Transducer set-up, D/C)
    Sheath Removal
    CARDIAC-Care of Patient With:
    Angina
    CHF
    Post MI
    Pre/Post Cardiac Cath
    Pre/Post Cardiac Surgery
    Open Sternal Wound (Debridement)
    Heart Transplant
    RESPIRATORY GENERAL SKILLS
    Establishing an Airway
    Ambuing Techniques
    Chest Tubes
    Pulse Oximetry
    Interpretation of ABG
    Use of IPPB
    Incentive Spirometer
    RESPIRATORY-Care of Patient With:
    COPD
    ARDS
    Pre/Post Thoracic Surgery
    Pulmonary Embolism
    Pulmonary Edema
    Pneumothorax
    Pneumonia
    Inhalation Injuries
    Emphysema
    Asthma
    Lung Transplant
    GASTROINTESTINAL GENERAL SKILLS
    NG Tube Insertion, Care and Maintenance
    Gastrostomy Tube
    Jejunostomy Tube
    Enterostomal Care
    Tube feedings
    GASTROINTESTINAL-Care of Patient With:
    Pancreatitis
    G.I. Bleed
    Esophageal Bleeding
    Bowel Obstruction
    Whipple Procedure
    Liver Transplant
    Paralytic Ileus
    E.R.C.P.
    GENITOURINARY/RENAL GENERAL SKILLS
    Peritoneal Dialysis
    Hemodialysis
    Foley/Straight Catheter Insertion
    GU Irrigations
    Nephrostomy Tube
    Suprapubic Tube
    Electrolyte Imbalance/Replacement
    GENITOURINARY/RENAL-Care of Patient With:
    T.U.R.P.
    Shunts & Fistulas
    Nephrectomy
    Renal Transplant
    Renal Trauma
    Chronic/Acute Renal Failure
    GYNECOLOGY GENERAL SKILLS
    GYN Exam/Pap
    GYNECOLOGY-Care of Patient With:
    Ectopic Pregnancy/Ruptured Ectopic Pregnancy
    Hysterectomy
    Repair of Cystocele/Rectocele
    ORTHOPEDIC GENERAL SKILLS
    Assessment of C/M/S
    K-Wires/Steinman Pins
    Removal of Hardware
    ORTHOPEDIC-Care of Patient With:
    Total Joint Replacement
    Spica Cast/Body Cast
    Amputation
    Traction
    Ortho Trauma
    Laminectomy
    ENDOCRINE GENERAL SKILLS
    Diabetic Teaching
    Blood Glucose Monitoring
    ENDOCRINE -Care of Patient With:
    Hyper/Hypoglycemia
    MEDICATION KNOWLEDGE AND USE OF:
    Insulin (IV,SQ)
    D50
    CARDIAC MONITORS:
    Other Cardiac Monitors:
    VENTILATORS:
    Other Ventilator/Weaning: