IMCS Group.gif   CNA Skills Checklist
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group 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.  
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

  
       
Rating Stars (Click) Patient Rights 1 2 3 4  
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) 		 
Involves the patient and family and respects their role in determining the
nature of care to be provided, including Advance Directives. 		 
Complies with nursing staff responsibility included in the hospital policy related to Organ Donation.  
Meets patient and families needs regarding communication, including interpreter services  
Provides accurate information to patient and families in a timely manner.   
Rating Stars (Click) Vital Signs and Weights 1 2 3 4  
BP, including Orthostatic  
Pulse, Radia  
Temperature, Oral  
Temperature, Rectal  
Temperature, Axillary  
Temperature, Tympanic  
Respirations  
Weight, Pounds and Kilograms  
Recognizing Cardiac Arrest  
Activating Code Team  
Bringing Emergency Equipment to Room  
Providing Appropriate Code Support  
Rating Stars (Click) Use of Electronic VS equipment:  1 2 3 4  
Automatic BP machine (Dynamap)  
Electronic Thermometer  
Applying Oximeter  
Rating Stars (Click) Scale Use:  1 2 3 4  
Standing  
Chair  
Bed  
Rating Stars (Click) GI /GU  1 2 3 4  
Report Abnormal Findings  
Bowel Function  
Bladder Function  
Rating Stars (Click) Administering Enemas:  1 2 3 4  
Tap Water  
Fleets  
Return Flow  
Rating Stars (Click) Vital Signs and Weights 1 2 3 4  
Placing and Removing Bed Pan  
Clamping Catheter  
Emptying Foley Bag  
Placing Condom Catheter  
Emptying and Replacing Ostomy Bag (Established Ostomy)  
Rating Stars (Click) Nutrition 1 2 3 4  
Estimating Intake  
Setting up for Meals  
Feeding Patients  
Aspiration Precautions  
Nourishments  
Counting Calories  
Fluid Restriction  
NPO  
Rating Stars (Click) Specimens 1 2 3 4  
Collecting Stool  
Collecting Sputum  
Labeling Specimens and Preparing for Transport  
Rating Stars (Click) Collecting Urine: 1 2 3 4  
Clean Catch  
24 Hour  
Rating Stars (Click) Hygiene /Skin 1 2 3 4  
Risk Factorsfor Skin Breakdown  
Observing Pressure Points for Redness or Breakdown  
Rating Stars (Click) Bathing /Daisy Hygiene:  1 2 3 4  
Bathing (Shower /Tub /Arjo)  
Oral Care, Including Patients who are NPO,Comatose, Patients with  
Pen Care  
Foot Care for Patients with Impaired Circulation or Sensation  
Incontinence Care  
Shaving and Precautions  
Reducing Pressure and Friction  
Rating Stars (Click) Use of Pressure and Friction Reduction Devices:  1 2 3 4  
Special Beds/Mattresses  
Heels and Elbow Protection  
Foot Cradles  
Use of Shower Chair  
Use of Bath/Shower Boat  
Rating Stars (Click) Infection Control 1 2 3 4  
Reverse Isolation  
Body Substance isolation  
TB Precautions  
MRSA Precautions  
Hand Washing  
Infectious/Hazardous Waste Disposal  
Supply/Equipment Disposal  
Use of Disposable Therrnomete  
Use of CPR Mask/Bag  
Rating Stars (Click) Proper use of Specific Barrier, Methods:  1 2 3 4  
Gloves  
Gown  
Mask / Goggles  
Rating Stars (Click) Safety and Activity 1 2 3 4  
Determining Patient ID  
Identifying Safety Hazards  
Determining Need for Additional Help  
Assessing Safety and ADL Needs  
Assessing Safety and ADL Needs  
Recognizing Abuse: Substance, Physical, Emotional, etc  
MaintainingClean, Orderly Work Area  
Disposing of Sharps  
Handling Hazardous Materials  
Proper Body Mechanics  
ROM Exercises  
Transferring to Bed,WC, Commode, etc  
Turning and Positioning  
Patient Safety Module  
Reporting Broken Equipment  
Responding to Safety Hazards  
Use of HoyerLift (Dextra /Maxi)  
Bed Operation  
Use of Wheel Locks  
Use of Alarms: Bed, Patient, Unit  
Use of CaIl Light  
Documenting Use of Restraints  
Use of Transfer Belt  
Use of Gait Belt for Ambulation  
Use of Seizure Pads  
Rating Stars (Click) Applicationof Restraints:  1 2 3 4  
Belt Including Seat Belt  
Wrist/Ankle  
Vest  
Rating Stars (Click) Care Routines 1 2 3 4  
Inventory andDispositionof Belongings, Useof Checklist  
Room Orientation, Call Bell  
Rating Stars (Click) Post-op Patient 1 2 3 4  
Transferring into Bed  
Call Bell  
Assist with Turns  
ROM Exercises  
Rating Stars (Click) Maintaining 02 Therapy 1 2 3 4  
Replacing Mask or Nasal Caunula if Needed  
Notifying Nurse of Problems  
Basic Comfort Measures  
Rating Stars (Click) Preparation For and Transfer to SNF 1 2 3 4  
Early Bath  
Preparing Belongings  
Preparingfor and Explaining Routinesto Patient  
Post Mortem Care  
Use ofIncentive Spirometer  
Rating Stars (Click) Removing /Replacing 1 2 3 4  
Antiembolic Stockings  
Sequential Stockings  
Rating Stars (Click) Communication  1 2 3 4  
Using Appropriate Abbreviations  
Identifying UnusuaI Patient Incidents that Require Reporting  
Reinforcing RN Teaching With Patient  
Selecting and Using Forms Appropriately  
Using Alternate Communication Tools /Devices  
Rating Stars (Click) Communicating to RN 1 2 3 4  
Changes in Patient Condition  
Patient Needs, Complaints and Concerns  
Unusual Incidents  
Rating Stars (Click) Recording and Reporting 1 2 3 4  
Vital Signs  
Bathing /Hygiene  
Turning and Repositioning  
Ambulation and Activity  
Diet intake, Calorie Count  
Bowel Movements  
Rating Stars (Click) 1 & 0 1 2 3 4  
Shift Volumes and Totals  
Marking and /or Measuring Amount of Urine, Gastric Fluid, NG Drainage,
Emesis, Diarrhea 		 
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)