Nurse Practitioner Checklist


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.

Total Stars:

Obtained Stars:

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

  Areas Worked         Rating Stars (Click) 1 2 3 4
  Emergency  
  Urgent Care  
  Private Practice  
  HMO  
  MD Office  
  Health Department  
  Ambulatory Clinic  
  Rural Health Clinic  
  Psychiatric Facility  
  Correctional Facility  
  Mobile Medical Unit  
  Corporate Worksite  
  Occupational Health  
  Rehabilitation  
  Nursing Home/ Long-term Care Facility  
  Women\'s Health Clinic  
  Government Health Agency  
  Hospice/Palliative Care�  
  Experience With         Rating Stars (Click) 1 2 3 4
  Diabetes  
  Contractures  
  Bedridden residents  
  Splinting of extremities  
  Local infiltration  
  Comprehensive physical assessment  
  Acute disease condition  
  Differential diagnosis  
  Order  
  may perform  
  & interpret screening & diagnostic test  
  Central line management  
  Disorders � Emergencies         Rating Stars (Click) 1 2 3 4
  Anaphylaxis  
  Cardiac arrest  
  Seizures  
  Minor head injuries  
  Animal bites  
  Ingestions and poisonings  
  Overdose of sedative  
  hypnotics  
  opiates  
  Snake bites  
  Minor burns  
  Shock  
  Open wounds  
  Collaboration         Rating Stars (Click) 1 2 3 4
  Family  
  support system  
  community resources  
  Consulting with Physicians  
  Consulting with Pharmacists  
  Consulting with Speech Therapist  
  Consulting with Dietician and Diet Aide  
  Consulting with Occupational Therapist  
  Referral to Pastoral Services  
  Respiratory         Rating Stars (Click) 1 2 3 4
  Croup  
  Influenza  
  Tracheobronchitis  
  Bronchitis  
  COPD (chronic obstructive pulmonary disease)  
  Asthma  
  URI (upper respiratory infection)  
  Obstructive Sleep Apnea  
  Viral  
  Bacterial  
  Bacterial  
  Nonbacteria  
  Oxygen administration  
  Liquid oxygen  
  IPPB machine use  
  Tracheotomies  
  Interpret ABG (blood gases)  
  Intubations  
  Sputum Collection  
  Cardiovascular System         Rating Stars (Click) 1 2 3 4
  Congestive heart failure  
  Chronic obstructive pulmonary disease  
  Stasis ulcer of lower extremities  
  Angina  
  Pericarditis  
  Coronary artery disease  
  Functional murmurs  
  Congenital heart disease  
  Hypertension  
  ASHD (arteriosclerotic heart disease)  
  Dyslipidemia  
  PVD (peripheral vascular disease)  
  Peripheral neuropathy  
  Interpreting 12 lead EKG�s  
  OB/GYN         Rating Stars (Click) 1 2 3 4
  Candida vaginitis  
  Dysmenorrhea  
  Abnormal pap smear findings  
  Pap smears  
  Trichomonal vaginitis  
  Atrophic vaginitis  
  Fibrocystic breast disease  
  Menopause  
  Intrapartum medications  
  Bartholin\'s cyst/abscess  
  Preparation for childbirth  
  Pregnancy - diagnosis and referral  
  Pain relief in active phase of labor  
  Medications in the third stage  
  Dysfunctional uterine bleeding  
  Medications in the postpartum phase  
  Rh blood factor  
  Mastitis  
  Birth control methods  
  Prenatal care  
  Fetal well-being  
  Nausea and vomiting with pregnancy  
  Pap smears  
  Pregnancy test kits  
  GI System         Rating Stars (Click) 1 2 3 4
  Constipation  
  Diarrhea (simple)  
  Acute gastroenteritis  
  Acute gastroenteritis  
  Pyloric stenosis  
  Colic  
  Appendicitis  
  Naso-gastric tubes  
  Gastrostomy Care  
  Skin         Rating Stars (Click) 1 2 3 4
  Warts  
  Basal cell carcinoma  
  Scabies  
  Impetigo  
  Diaper dermatitis  
  Acne  
  Folliculitis  
  Furuncles  
  Carbuncles  
  Herpes Simplex  
  Herpes Zoster  
  Malignant melanoma  
  Pityriasis Rosea  
  Contact dermatitis  
  Tinea corporis  
  Tinea pedis  
  Staph infections  
  Wound care  
  Single layer wound closure  
  Incision and drainage  
  Excisions  
  Ears, Nose and Throat         Rating Stars (Click) 1 2 3 4
  Epistaxis  
  Otitis externa  
  Serous otitis media  
  Acute purulent otitis media  
  Allergic rhinitis  
  Pharyngitis  
  Oral candidiasis  
  Eye         Rating Stars (Click) 1 2 3 4
  Conjunctivitis  
  lStrabismus  
  Chalazion  
  Stye  
  Visual acuity  
  Fluorescein staining of eyes  
  Audiometr  
  Tympanometry  
  Musculoskeletal         Rating Stars (Click) 1 2 3 4
  Osteoporosisk  
  Osteomyelitis  
  Rheumatoid arthritis  
  Juvenile diabetes  
  Gout  
  Minor sprains and strains  
  Osteoarthritis  
  Carpal tunnel syndrome  
  Scoliosis  
  Tendonitis  
  Bursitis  
  Muscular dystrophy  
  Parasitic Infections         Rating Stars (Click) 1 2 3 4
  Pinworms  
  Ascariasis  
  Pediculosis  
  Genitourinary System         Rating Stars (Click) 1 2 3 4
  Syphilis  
  Chlamydia  
  Herpes  
  Cystitis  
  Pyelonephritis  
  Urinary tract infection  
  Benign prostatic hypertrophy  
  Vulvovaginitis  
  Hypospadias  
  Hydrocele  
  Gonococcal infections  
  Prostatitis  
  Catheter Care  
  Incontinence care-bowel  
  Dermal ulcers  
  Enemas/ Suppositories/ Fecal  
  Urine collection  
  Nervous System         Rating Stars (Click) 1 2 3 4
  Vasovagal syncope  
  Migraine headaches  
  Multiple sclerosis  
  Headaches  
  Head injury  
  Tension  
  Anxiety  
  Parkinson�s  
  Alzheimer�s  
  Bell�s Palsy  
  TIA (transient ischemic attacks)  
  Trigeminal neuralgia  
  Endocrine         Rating Stars (Click) 1 2 3 4
  Type I diabetes mellitus  
  Type II diabetes mellitus  
  Graves disease  
  Addison\'s disease  
  Juvenile diabetes  
  Hypoglycemia  
  Hypothyroidism  
  Hematological         Rating Stars (Click) 1 2 3 4
  Folic acid deficiency anemia  
  Aplastic anemia  
  Iron deficiency  
  Sickle cell anemia  
  Pernicious anemia  
  Hemoglobinmeter  
  Psychosocial         Rating Stars (Click) 1 2 3 4
  Depression  
  Suicide  
  Obesity  
  Grief  
  Anxiety  
  Anorexia  
  Bulimia  
  Drug Therapy         Rating Stars (Click) 1 2 3 4
  Prescription  
  Over the counter (OTC)  
  Herbal drugs  
  Knowledge of pharmacology  
  Knowledge of pharmacokinetics  
  Knowledge of drug interactions  
  Knowledge of side effects  
  Allergic reactions  
  Anaphylaxis reaction  
  TPN/Lipid Management  
  Management/Titration of IV Therapies  
  IV/PO Antibiotic Therapy and understanding of cultures  
  Dispensing Medication         Rating Stars (Click) 1 2 3 4
  Monitoring drug therapy  
  Management of controlled substances  
  Injections  
  Non-Pharmacologic Interventions         Rating Stars (Click) 1 2 3 4
  Medical nutrition therapy  
  Exercise  
  Cessation of substance abuse (alcohol  
  tobacco)  
  Mental health issues (stress management  
  depression)  
  Obesity management  
  Tube Feeding Management  
  Miscellaneous         Rating Stars (Click) 1 2 3 4
  Public health and health promotion�  
  Research  
  Quality assurance  
  Leadership and teaching skills  
  Legal and ethical issues  
  Confidentiality  
  Cultural awareness  
  Self evaluation to improve patient care  
  Continuing education  
  Working within scope of practice  
  Discharge planning / collaboration  
  Suturing  
  Programs         Rating Stars (Click) 1 2 3 4
  OSHA (Occupational Safety and Health Administration)  
  Medicare and Medicaid  
  CLIA waiver (Clinical Laboratory Improvement Amendments)  
  TJC (The Joint Commission)  
  HEDIS (Health Plan Employer Data and Information Set)  
  DQIP (Diabetes Quality Improvement Program)  
  HIPAA (Health Insurance Portability & Accountability Act)  
  HCAHPS  
  Age Specific Competencies         Rating Stars (Click) 1 2 3 4
  Newborn/neonate (birth-30 days)  
  Infant (31 days-1 year)  
  Toddler (ages 2-3 years)  
  Preschool (ages 4-5 years)  
  School age (ages 6-12 years)  
  Adolescents (ages 13-21 years)  
  Young adult (ages 22-39 years)  
  Adults (ages 40-64 years)  
  Older adult (ages 65-79 years)  
  Elderly (ages 80+ years)