Checklist Form

Pediatric ER

* 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

CARDIOVASCULAR

Cardiac Anomalies		Rated 0 stars out of 4
CHF/Pulmonary Edema		Rated 0 stars out of 4
Cardiogenic Shock		Rated 0 stars out of 4
Cardioversion		Rated 0 stars out of 4
Heart Sounds		Rated 0 stars out of 4

PULMONARY

Reactive Airway Disease		Rated 0 stars out of 4
Croup		Rated 0 stars out of 4
Pneumonia		Rated 0 stars out of 4
Epiglottitis		Rated 0 stars out of 4
Aspiration		Rated 0 stars out of 4
Airway Obstruction		Rated 0 stars out of 4
Hemo/Pneumothorax		Rated 0 stars out of 4
Chest Tube Placement/Management		Rated 0 stars out of 4
ABG Interpretation		Rated 0 stars out of 4

NEUROLOGICAL

Meningitis/Encephalitis		Rated 0 stars out of 4
Seizures-Febrile/Epileptic		Rated 0 stars out of 4
Lumbar Puncture		Rated 0 stars out of 4
Migraine		Rated 0 stars out of 4

ORTHOPEDIC

Fractures/Casting		Rated 0 stars out of 4
Open/Complex Fractures		Rated 0 stars out of 4
Nursemaid's Elbow		Rated 0 stars out of 4
Apply/Manage Splints		Rated 0 stars out of 4
Circulation Checks		Rated 0 stars out of 4
Crutch Walking		Rated 0 stars out of 4
Car Seat Instruction for Casted Patient		Rated 0 stars out of 4

GASTROINTESTINAL

Abdominal Trauma/Peritoneal Lavage		Rated 0 stars out of 4
Abdominal Pain		Rated 0 stars out of 4
Constipation		Rated 0 stars out of 4
GI Bleeding		Rated 0 stars out of 4
Hepatitis/Liver Failure		Rated 0 stars out of 4
Poison Ingestion		Rated 0 stars out of 4

ENDOCRINE/METABOLIC

Hypoglycemia		Rated 0 stars out of 4
Hyperglycemia		Rated 0 stars out of 4
DKA		Rated 0 stars out of 4

GENITOURINARY

Acute Renal Failure		Rated 0 stars out of 4
UTI/Pyelonephritis		Rated 0 stars out of 4
Renal Trauma		Rated 0 stars out of 4
Testicular Torsion		Rated 0 stars out of 4

OB/GYN

Menstrual Pain		Rated 0 stars out of 4
Ovarian Cyst		Rated 0 stars out of 4
Ectopic Pregnancy		Rated 0 stars out of 4
Pelvic Inflammatory Disease/STD		Rated 0 stars out of 4
Sexual Assault		Rated 0 stars out of 4
Reporting Acts of Violence		Rated 0 stars out of 4

EENT

Foreign Body - Eye		Rated 0 stars out of 4
Foreign Body - Ear		Rated 0 stars out of 4
Foreign Body - Nose		Rated 0 stars out of 4
Epistaxis		Rated 0 stars out of 4

TRAUMA

Glasgow Coma/Pediatric Trauma Scale		Rated 0 stars out of 4
Trauma Code		Rated 0 stars out of 4
Trauma Team Member		Rated 0 stars out of 4
Brain Injury		Rated 0 stars out of 4
Spinal Cord Injury		Rated 0 stars out of 4
Spinal Precautions		Rated 0 stars out of 4
Facial/Dental Trauma		Rated 0 stars out of 4
Penetrating Trauma		Rated 0 stars out of 4
Blunt Trauma		Rated 0 stars out of 4
Traumatic Amputation		Rated 0 stars out of 4
Hypovolemic Shock		Rated 0 stars out of 4
Neurogenic Shock		Rated 0 stars out of 4
Anaphylactic Shock		Rated 0 stars out of 4
Septic Shock		Rated 0 stars out of 4
Burns - 2nd Degree		Rated 0 stars out of 4
Burns - 3rd Degree		Rated 0 stars out of 4

INFECTIOUS DISEASE/IMMUNOSUPPRESSION

Contagious/Infectious Patients		Rated 0 stars out of 4
Isolation		Rated 0 stars out of 4
Reporting Communicable Disease		Rated 0 stars out of 4
Neutropenia/Reverse Isolation		Rated 0 stars out of 4

PSYCHIATRIC

Drug /ETOH Overdose/Withdrawal		Rated 0 stars out of 4
Psychiatric Hold		Rated 0 stars out of 4
Suicidal Patient		Rated 0 stars out of 4

MEDICATIONS

Pediatric Dosage Calculations		Rated 0 stars out of 4
Anti-Arrhythmics		Rated 0 stars out of 4
Anticoagulants (IV, Oral & Injection)		Rated 0 stars out of 4
Anti-Hypertensives		Rated 0 stars out of 4
Anti-Psychotics		Rated 0 stars out of 4
Anti-Seizure Medications		Rated 0 stars out of 4
Benzodiazepines		Rated 0 stars out of 4
Continuous IV Paralytics		Rated 0 stars out of 4
Continuous IV Sedation		Rated 0 stars out of 4
Procedural Sedation - Administration		Rated 0 stars out of 4
Ketamine		Rated 0 stars out of 4
Emergency Medications		Rated 0 stars out of 4
Inhaled Medications		Rated 0 stars out of 4
Insulin		Rated 0 stars out of 4
IV Vasopressors		Rated 0 stars out of 4
Narcotics/Opioid Analgesics (IV, Oral & Injection)		Rated 0 stars out of 4
Reversal Agents		Rated 0 stars out of 4
Steroids (IV, Oral & Inhaled)		Rated 0 stars out of 4
Automated Medication Dispensing (i.e. Pyxis, Omnicell)		Rated 0 stars out of 4

PROFESSIONAL KNOWLEDGE AND SKILLS

Recognizing/Reporting Abuse		Rated 0 stars out of 4
Triage		Rated 0 stars out of 4
Ambulance/Paramedic Radio		Rated 0 stars out of 4
Charge Experience		Rated 0 stars out of 4
EMTALA		Rated 0 stars out of 4
National Patient Safety Goals/Core Measures		Rated 0 stars out of 4
Fall Risk Assessment/Prevention		Rated 0 stars out of 4
Pressure Ulcer Risk Assessment/Prevention		Rated 0 stars out of 4
Restraints/Use of Least Restrictive Device		Rated 0 stars out of 4
Patient Family Teaching		Rated 0 stars out of 4
Car Seat Specific Standards/Teaching		Rated 0 stars out of 4
Age/Developmentally Specific/Population Based Care		Rated 0 stars out of 4
Pain Assessment and Management - Verbal/Non-Verbal		Rated 0 stars out of 4
Interpretation and Communication of Lab Values		Rated 0 stars out of 4

EMR

Epic		Rated 0 stars out of 4
Cerner		Rated 0 stars out of 4
Eclipsys		Rated 0 stars out of 4
McKesson		Rated 0 stars out of 4
Meditech		Rated 0 stars out of 4
Allscripts		Rated 0 stars out of 4
Other Computerized System		Rated 0 stars out of 4
Computerized Physician Order Entry		Rated 0 stars out of 4
Bar Coding for Medication Administration		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.

BLS
PALS
PEARS
ACLS
TNCC
ENPC
CEN
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