Checklist Form

Travel Nursing

* 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

CARDIAC

Acute Coronary Syndrome		Rated 0 stars out of 4
Congestive Heart Failure		Rated 0 stars out of 4
Post Open Heart (12-24 hours)		Rated 0 stars out of 4
Carotid Endarterectomy		Rated 0 stars out of 4
Post Vascular Surgery		Rated 0 stars out of 4
Heart Transplant		Rated 0 stars out of 4
Pacemaker - Temporary/Permanent		Rated 0 stars out of 4
Pacemaker - Epicardial		Rated 0 stars out of 4
Sheath Removal		Rated 0 stars out of 4
Heart Sounds		Rated 0 stars out of 4

PULMONARY

Pneumonia		Rated 0 stars out of 4
Respiratory Distress		Rated 0 stars out of 4
COPD		Rated 0 stars out of 4
Breath Sounds		Rated 0 stars out of 4
Post Thoracic Surgery		Rated 0 stars out of 4
Chest Tube Placement & Management		Rated 0 stars out of 4
Trach Management		Rated 0 stars out of 4
Modes of Ventilation (AC/PC/SIMV/CPAP)		Rated 0 stars out of 4
Intubation/Extubation		Rated 0 stars out of 4
External CPAP/BiPAP		Rated 0 stars out of 4
Interpretation of Arterial Blood Gases		Rated 0 stars out of 4

NEUROLOGIC & PSYCHIATRIC

Stroke Scale Assessment		Rated 0 stars out of 4
CVA		Rated 0 stars out of 4
Brain Injury		Rated 0 stars out of 4
Post Craniotomy		Rated 0 stars out of 4
Spinal Cord Injury		Rated 0 stars out of 4
Seizure Disorders		Rated 0 stars out of 4
ETOH/Drug Withdrawal		Rated 0 stars out of 4

GASTROINTESTINAL

GI Bleeding		Rated 0 stars out of 4
GI Surgery		Rated 0 stars out of 4
Liver Failure		Rated 0 stars out of 4
Pancreatitis		Rated 0 stars out of 4
Liver Transplant		Rated 0 stars out of 4
Pancreas Transplant		Rated 0 stars out of 4

RENAL/GENITOURINARY

Renal Failure		Rated 0 stars out of 4
Renal Surgery		Rated 0 stars out of 4
Renal Transplant		Rated 0 stars out of 4
Arteriovenous Fistula/Shunt		Rated 0 stars out of 4
Nephrostomy Tubes		Rated 0 stars out of 4
Peritoneal Dialysis		Rated 0 stars out of 4

ENDOCRINE METABOLIC

Diabetes - Hypo/Hyperglycemic Crisis		Rated 0 stars out of 4
Pituitary Disorders		Rated 0 stars out of 4
IV Insulin Protocols		Rated 0 stars out of 4
Indwelling Insulin Pumps		Rated 0 stars out of 4

MEDICATIONS

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
Procedural Sedation		Rated 0 stars out of 4
Diuretics		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
Titrate Vasoactive Drips		Rated 0 stars out of 4
Manage Vasoactive Drips - No Titration		Rated 0 stars out of 4
Narcotics/Opioid Analgesics (IV, oral, & injection)		Rated 0 stars out of 4
Nitrates (Oral & Topical)		Rated 0 stars out of 4
Non-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

IV THERAPY

Starting Ivs		Rated 0 stars out of 4
Central Line Blood Draws		Rated 0 stars out of 4
Central Line/Implanted Line Care		Rated 0 stars out of 4
Arterial Line Management		Rated 0 stars out of 4
TPN & Lipids		Rated 0 stars out of 4
Blood Product Administration		Rated 0 stars out of 4
Administration of Chemotherapy		Rated 0 stars out of 4

CARDIAC MONITORING & EMERG. RESPONSE

Dysrhythmia Interpretation		Rated 0 stars out of 4
Dysrhythmia Management		Rated 0 stars out of 4
Obtain 12 Lead EKG		Rated 0 stars out of 4
Interpret 12 Lead EKG		Rated 0 stars out of 4
Cardioversion		Rated 0 stars out of 4
Defibrillation		Rated 0 stars out of 4
Malignant Hyperthermia		Rated 0 stars out of 4

PROFESSIONAL KNOWLEDGE AND SKILLS

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
Age Specific/Population-Based Care		Rated 0 stars out of 4
Isolation Precautions		Rated 0 stars out of 4
Infection Prevention		Rated 0 stars out of 4
Pain Assessment & Management		Rated 0 stars out of 4
Charge Experience		Rated 0 stars out of 4
Interpretation and Communication of Lab Values		Rated 0 stars out of 4
Specialty Beds		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

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
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
EMR Conversion

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
ACLS
PALS
PCCN
CCRN
Critical Care Course
Telemetry Certificate/Course
Other: Specify