Checklist Form

PCT

* 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

Patient Rights

Communicates and obtains information while respecting the rights and privacy and confidentiality of information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)		Rated 0 stars out of 4
Involves the patient and family and respects their role in determining the nature of care to be provided, including Advance Directives.		Rated 0 stars out of 4
Complies with nursing staff responsibility included in the hospital policy related to Organ Donation.		Rated 0 stars out of 4
Meets patient and families needs regarding communication, including interpreter services		Rated 0 stars out of 4
Provides accurate information to patient and families in a timely manner.		Rated 0 stars out of 4

Vital Signs and Weights

BP, including Orthostatic		Rated 0 stars out of 4
Pulse, Radia		Rated 0 stars out of 4
Temperature, Oral		Rated 0 stars out of 4
Temperature, Rectal		Rated 0 stars out of 4
Temperature, Axillary		Rated 0 stars out of 4
Temperature, Tympanic		Rated 0 stars out of 4
Respirations		Rated 0 stars out of 4
Weight, Pounds and Kilograms		Rated 0 stars out of 4
Recognizing Cardiac Arrest		Rated 0 stars out of 4
Activating Code Team		Rated 0 stars out of 4
Bringing Emergency Equipment to Room		Rated 0 stars out of 4
Providing Appropriate Code Support		Rated 0 stars out of 4
Automatic BP machine (Dynamap)		Rated 0 stars out of 4
Electronic Thermometer		Rated 0 stars out of 4
Applying Oximeter		Rated 0 stars out of 4
Standing		Rated 0 stars out of 4
Chair		Rated 0 stars out of 4
Bed		Rated 0 stars out of 4
Report Abnormal Findings		Rated 0 stars out of 4
Bowel Function		Rated 0 stars out of 4
Bladder Function		Rated 0 stars out of 4
Tap Water		Rated 0 stars out of 4
Fleets		Rated 0 stars out of 4
Return Flow		Rated 0 stars out of 4
Placing and Removing Bed Pan		Rated 0 stars out of 4
Clamping Catheter		Rated 0 stars out of 4
Emptying Foley Bag		Rated 0 stars out of 4
Placing Condom Catheter		Rated 0 stars out of 4
Emptying and Replacing Ostomy Bag (Established Ostomy)		Rated 0 stars out of 4

Nutrition

Estimating Intake		Rated 0 stars out of 4
Setting up for Meals		Rated 0 stars out of 4
Feeding Patients		Rated 0 stars out of 4
Aspiration Precautions		Rated 0 stars out of 4
Nourishments		Rated 0 stars out of 4
Counting Calories		Rated 0 stars out of 4
Fluid Restriction		Rated 0 stars out of 4
NPO		Rated 0 stars out of 4

Specimens

Collecting Stool		Rated 0 stars out of 4
Collecting Sputum		Rated 0 stars out of 4
Labeling Specimens and Preparing for Transport		Rated 0 stars out of 4
Clean Catch		Rated 0 stars out of 4
24 Hour		Rated 0 stars out of 4

Hygiene /Skin

Risk Factorsfor Skin Breakdown		Rated 0 stars out of 4
Observing Pressure Points for Redness or Breakdown		Rated 0 stars out of 4
Bathing (Shower /Tub /Arjo)		Rated 0 stars out of 4
Oral Care, Including Patients who are NPO,Comatose, Patients with		Rated 0 stars out of 4
Pen Care		Rated 0 stars out of 4
Foot Care for Patients with Impaired Circulation or Sensation		Rated 0 stars out of 4
Incontinence Care		Rated 0 stars out of 4
Shaving and Precautions		Rated 0 stars out of 4
Reducing Pressure and Friction		Rated 0 stars out of 4
Special Beds/Mattresses		Rated 0 stars out of 4
Heels and Elbow Protection		Rated 0 stars out of 4
Foot Cradles		Rated 0 stars out of 4
Use of Shower Chair		Rated 0 stars out of 4
Use of Bath/Shower Boat		Rated 0 stars out of 4

Infection Control

Reverse Isolation		Rated 0 stars out of 4
Body Substance isolation		Rated 0 stars out of 4
TB Precautions		Rated 0 stars out of 4
MRSA Precautions		Rated 0 stars out of 4
Hand Washing		Rated 0 stars out of 4
Infectious/Hazardous Waste Disposal		Rated 0 stars out of 4
Supply/Equipment Disposal		Rated 0 stars out of 4
Use of Disposable Therrnomete		Rated 0 stars out of 4
Use of CPR Mask/Bag		Rated 0 stars out of 4
Gloves		Rated 0 stars out of 4
Gown		Rated 0 stars out of 4
Mask / Goggles		Rated 0 stars out of 4

Safety and Activity

Determining Patient ID		Rated 0 stars out of 4
Identifying Safety Hazards		Rated 0 stars out of 4
Determining Need for Additional Help		Rated 0 stars out of 4
Assessing Safety and ADL Needs		Rated 0 stars out of 4
Recognizing Abuse: Substance, Physical, Emotional, etc		Rated 0 stars out of 4
MaintainingClean, Orderly Work Area		Rated 0 stars out of 4
Disposing of Sharps		Rated 0 stars out of 4
Handling Hazardous Materials		Rated 0 stars out of 4
Proper Body Mechanics		Rated 0 stars out of 4
ROM Exercises		Rated 0 stars out of 4
Transferring to Bed,WC, Commode, etc		Rated 0 stars out of 4
Turning and Positioning		Rated 0 stars out of 4
Patient Safety Module		Rated 0 stars out of 4
Reporting Broken Equipment		Rated 0 stars out of 4
Responding to Safety Hazards		Rated 0 stars out of 4
Use of HoyerLift (Dextra /Maxi)		Rated 0 stars out of 4
Bed Operation		Rated 0 stars out of 4
Use of Wheel Locks		Rated 0 stars out of 4
Use of Alarms: Bed, Patient, Unit		Rated 0 stars out of 4
Use of CaIl Light		Rated 0 stars out of 4
Documenting Use of Restraints		Rated 0 stars out of 4
Use of Transfer Belt		Rated 0 stars out of 4
Use of Gait Belt for Ambulation		Rated 0 stars out of 4
Use of Seizure Pads		Rated 0 stars out of 4
Belt Including Seat Belt		Rated 0 stars out of 4
Wrist/Ankle		Rated 0 stars out of 4
Vest		Rated 0 stars out of 4

Care Routines

Inventory andDispositionof Belongings, Useof Checklist		Rated 0 stars out of 4
Room Orientation, Call Bell		Rated 0 stars out of 4
Transferring into Bed		Rated 0 stars out of 4
Call Bell		Rated 0 stars out of 4
Assist with Turns		Rated 0 stars out of 4
ROM Exercises		Rated 0 stars out of 4
Replacing Mask or Nasal Caunula if Needed		Rated 0 stars out of 4
Notifying Nurse of Problems		Rated 0 stars out of 4
Basic Comfort Measures		Rated 0 stars out of 4
Early Bath		Rated 0 stars out of 4
Preparing Belongings		Rated 0 stars out of 4
Preparingfor and Explaining Routinesto Patient		Rated 0 stars out of 4
Post Mortem Care		Rated 0 stars out of 4
Use ofIncentive Spirometer		Rated 0 stars out of 4
Antiembolic Stockings		Rated 0 stars out of 4
Sequential Stockings		Rated 0 stars out of 4

Communication

Using Appropriate Abbreviations		Rated 0 stars out of 4
Identifying UnusuaI Patient Incidents that Require Reporting		Rated 0 stars out of 4
Reinforcing RN Teaching With Patient		Rated 0 stars out of 4
Selecting and Using Forms Appropriately		Rated 0 stars out of 4
Using Alternate Communication Tools /Devices		Rated 0 stars out of 4
Changes in Patient Condition		Rated 0 stars out of 4
Patient Needs, Complaints and Concerns		Rated 0 stars out of 4
Unusual Incidents		Rated 0 stars out of 4
Vital Signs		Rated 0 stars out of 4
Bathing /Hygiene		Rated 0 stars out of 4
Turning and Repositioning		Rated 0 stars out of 4
Ambulation and Activity		Rated 0 stars out of 4
Diet intake, Calorie Count		Rated 0 stars out of 4
Bowel Movements		Rated 0 stars out of 4
Shift Volumes and Totals		Rated 0 stars out of 4
Marking and /or Measuring Amount of Urine, Gastric Fluid, NG Drainage, Emesis, Diarrhea		Rated 0 stars out of 4

Unit Activity

Identifying Unusual Incidents on the Unit that Require Reporting		Rated 0 stars out of 4
Locating and Using Appropriate Reference Materials: Hospital, Patient Care and		Rated 0 stars out of 4
Charging for Patient Care Items		Rated 0 stars out of 4
Completing Risk Management Reports as Needed		Rated 0 stars out of 4
Obtaining Needed Supplies and Equipment		Rated 0 stars out of 4
Reporting and Following up on Faulty Equipment and Supplies		Rated 0 stars out of 4
Using Telephone System		Rated 0 stars out of 4

Age Specific Competencies

Infant (Birth - 1 year)		Rated 0 stars out of 4
Preschooler (ages 2-5 years)		Rated 0 stars out of 4
Childhood (ages 6-12 years)		Rated 0 stars out of 4
Adolescents (ages 13-21 years)		Rated 0 stars out of 4
Young Adults (ages 22-39 years)		Rated 0 stars out of 4
Adults (ages 40-64 years)		Rated 0 stars out of 4
Older Adults (ages 65-79 years)		Rated 0 stars out of 4
Elderly (ages 80+ years)		Rated 0 stars out of 4

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.

PCT