Checklist Form

Psychiatric Tech

* Name

* Email

* LAST 4 OF SSN

This checklist was electronically signed on (Today’s date)

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.

Proficiency Scale: 1 = No Experience 2 = Need Training 3 = Able to perform with supervision 4 = Able to perform independently

Proficiency Scale

General Duties		Rated 0 stars out of 4
Admit/Orient Involuntary Clients		Rated 0 stars out of 4
Admit/Orient Voluntary Clients		Rated 0 stars out of 4
Advance Directives		Rated 0 stars out of 4
Ambulatory Cuffs		Rated 0 stars out of 4
Assist Activities of Daily Living		Rated 0 stars out of 4
Assist with Personal Hygiene		Rated 0 stars out of 4
Cultural Diversity		Rated 0 stars out of 4
Discharge Clients		Rated 0 stars out of 4
Discharge Planning		Rated 0 stars out of 4
Documentation-Computer		Rated 0 stars out of 4
Documentation-Written		Rated 0 stars out of 4
Full Restraints		Rated 0 stars out of 4
HIPAA Regulations		Rated 0 stars out of 4
Initial Interview		Rated 0 stars out of 4
Initial Screening Assessment		Rated 0 stars out of 4
Isolation Techniques		Rated 0 stars out of 4
Mutli-Disciplinary Planning		Rated 0 stars out of 4
Oxygen Administration		Rated 0 stars out of 4
Participate in Interdisciplinary Team		Rated 0 stars out of 4
Patient Teaching		Rated 0 stars out of 4
Reassess/Update Plan of Care		Rated 0 stars out of 4
Referral to Community Resources		Rated 0 stars out of 4
Supervise Unlicensed Personnel		Rated 0 stars out of 4
Vital Signs		Rated 0 stars out of 4
Wrist Restraints		Rated 0 stars out of 4

Eating Disorders

Anorexia Nervosa		Rated 0 stars out of 4
Bulimia Nervosa		Rated 0 stars out of 4
Obesity		Rated 0 stars out of 4
Interventions/Therapies		Rated 0 stars out of 4
Assultive Behavior		Rated 0 stars out of 4

Care of Psychiatric Disorders

Anxiety Disorders		Rated 0 stars out of 4
Bipolar Disorder		Rated 0 stars out of 4
Catatonic Psychotic Disorder		Rated 0 stars out of 4
Delusional Disorders		Rated 0 stars out of 4
Depression		Rated 0 stars out of 4
Dissociative Identity Disorder		Rated 0 stars out of 4
Hallucinations		Rated 0 stars out of 4
Obsessive/Compulsive Disorder		Rated 0 stars out of 4
Panic Attacks		Rated 0 stars out of 4
Paranoid Psychotic Disorder		Rated 0 stars out of 4
Phobias		Rated 0 stars out of 4
Schizophrenia		Rated 0 stars out of 4
Suicidal Ideation/Attempts		Rated 0 stars out of 4

Assist with Psychotherapy

Behavioral		Rated 0 stars out of 4
Couple/Family		Rated 0 stars out of 4
Group		Rated 0 stars out of 4
Individual		Rated 0 stars out of 4

Personality Disorders

Cluster A-Paranoid/Schizoid		Rated 0 stars out of 4
Cluster B-Antisocial/Borderline		Rated 0 stars out of 4
Cluster C-Anxious/Fearful		Rated 0 stars out of 4

Cognitive Disorders

Alzheimer's (Dementia)		Rated 0 stars out of 4
Amnestic Disorders		Rated 0 stars out of 4
Delirium		Rated 0 stars out of 4
Dementia		Rated 0 stars out of 4

Certified "Management of Assultive Behavior"

Crisis Intervention		Rated 0 stars out of 4
Drug & Alcohol Education		Rated 0 stars out of 4
Education or Vocational Training		Rated 0 stars out of 4
Teach Independent Living Skills		Rated 0 stars out of 4
Therapeutic Communication		Rated 0 stars out of 4
Therapeutic Milieu		Rated 0 stars out of 4

Assist with Alternative Therapies:

Biofeedback		Rated 0 stars out of 4
ElectroConvulsive Therapy		Rated 0 stars out of 4
Expressive Therapy (Art, Movement)		Rated 0 stars out of 4
Guided Imagery		Rated 0 stars out of 4
Massage Therapy		Rated 0 stars out of 4
Mediation		Rated 0 stars out of 4
Recreational Therapy		Rated 0 stars out of 4
Therapeutic Touch		Rated 0 stars out of 4

Meds/IV Therapy

Administer IM & SQ Meds		Rated 0 stars out of 4
Administer PO Medications		Rated 0 stars out of 4
Administer Topical Medications		Rated 0 stars out of 4
Identify Appropriate Level of Care		Rated 0 stars out of 4
Discontinue Peripheral IV's		Rated 0 stars out of 4
Pain Assessment/Management		Rated 0 stars out of 4

Substance-Related Disorders:

ADHD		Rated 0 stars out of 4
Alcohol-Related		Rated 0 stars out of 4
Developemntal/Autistic Disorders		Rated 0 stars out of 4
Drug-Related		Rated 0 stars out of 4
Mental Retardation		Rated 0 stars out of 4
Post Traumatic Stress Disorder		Rated 0 stars out of 4
Sexual Abuse/Assault		Rated 0 stars out of 4
Sexual Disorders		Rated 0 stars out of 4
Somatoform Disorders (Pain etc.)		Rated 0 stars out of 4
Survivor of Abuse/Violence		Rated 0 stars out of 4

Psychotropic Agents:

Antianxiety Agents		Rated 0 stars out of 4
Anticholinergics/Antiparkinsons		Rated 0 stars out of 4
Anticonvulsants		Rated 0 stars out of 4
Antidepressants/Mood Elevators		Rated 0 stars out of 4
Antimanic Agents		Rated 0 stars out of 4
Antipsychotic Agents		Rated 0 stars out of 4
Hypnotics		Rated 0 stars out of 4
Management of Med Side Effects		Rated 0 stars out of 4
Recognition of Med Side Effects		Rated 0 stars out of 4

PROFICIENCY SCALE

Newborn (birth-30 days)		Rated 0 stars out of 4
Infant (30 days-1 yrs)		Rated 0 stars out of 4
Toddler (1-3 yrs)		Rated 0 stars out of 4
Preschooler (3-5 yrs)		Rated 0 stars out of 4
School Age (5-12 yrs)		Rated 0 stars out of 4
Adolescents (12-18 yrs)		Rated 0 stars out of 4
Young Adults (18-39 yrs)		Rated 0 stars out of 4
Middle Adults (39-64 yrs)		Rated 0 stars out of 4
Older Adults (64 yrs +)		Rated 0 stars out of 4

Years of Experience Continuum of Care Settings Hospital Settings

Med-Psych Unit
Transitional Care Hospital
Freestanding Psych Hospital
Community-Based Hospital
Subacute Care Units
Long-Term Care Facilities

Community Mental Health Services

Emergency Clinic
Day Treatment Programs
Residential Programs
Home Care
Aftercare/Rehab Clinic
Corrections/ Prison

Signature

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.