Long Term Care/Sub Acute Care Checklist

NAME

LAST 4 OF SSN

Date of application

E-MAIL

I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

CARDIAC	Rating Stars (Click)	1	2	3	4
Use of cardiac monitors
Assessment of heart sounds
Cardiac Arrest
CPR
Care of patients with CHF
Atropine administration
Digoxin administration
Dopamine administration
Inderal administration
Lidocaine administration
GENITOURINARY	Rating Stars (Click)	1	2	3	4
Fluid Balance
Foley Catheter Insertion
Ileostomy
GU Irrigations
Nephrostomy Tube
ENDOCRINE	Rating Stars (Click)	1	2	3	4
Blood Glucose Checks
Insulin Administration
Care of patients with Diabetes
GASTROINTESTINAL	Rating Stars (Click)	1	2	3	4
NG tube care and feedings
Gastrostomy tube care and feedings
Colostomy Care
Assessment of Bowel Sounds
LEADERSHIP/PATIENT CARE	Rating Stars (Click)	1	2	3	4
Taking Charge�
Admission Procedures
Discharge Procedures
Patient Education
Patient Care Plans
MEDICATIONS/IV THERAPY	Rating Stars (Click)	1	2	3	4
Medication Calculation
Reconstitution
Oral Administration
Eye Administration
IM Administration
SQ Administration
Rectal Administration
Starting IV�s
IV Medication Administration
Central Line Care
NEUROLOGY	Rating Stars (Click)	1	2	3	4
Assessment of Neurological Status
Seizure Precautions
Care of a patient with a CVA
Care of a patient with Alzheimer�s
Care of patients with Spinal Cord Injury
Decadron Administration
Dilantin Administration
Phenobarbital Administration
Valium Administration
ORTHO/SKIN	Rating Stars (Click)	1	2	3	4
Assessment of skin
Wound Care and Treatments
Use of special pressure relief devices
Care of pts with a total hip replacement
Care of pts with a total knee replacement
Crutch Walking
RESPIRATORY	Rating Stars (Click)	1	2	3	4
Pulse Oximetry
Oxygen Administration via nasal cannuia
Oxygen Administration via face mask
Principles of chest percussion
Care of patients with ventilator
Care of patients with COPD
Care of patients with ARDS
Care of patient with a Tracheotomy
Age Specific Competencies	Rating Stars (Click)	1	2	3	4
Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)
Elderly (ages 80+ years)