MED_SURG_CHECKLIST

		Medical/Surgical Skill 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)	General Skills		1	2	3	4
	Advanced directives
	Patient/family teaching
	Restrictive devices (restraints)
	Lift/transfer devices
	Specialty beds
	End of life care/palliative care
	Automated Medication Dispensing System, Pyxis, Omnicell, or other
	Bar coding for medication administration
	National Patient Safety Goals
	Accurate patient identification
	Effective communication
	Interpretation & communication of lab values
	Medication administration
	Labeling
	Anticoagulation therapy
	Reconciliation
	Monitoring conscious sedation
	Pain assessment & management
	Use of PCA (IV, intrathecal, epidural)
	Infection control
	Universal precautions
	Isolation
	Minimize risk for falls
	Prevention of pressure ulcers
	Wound care
	Wound vacs
	Awareness of HCAHPS
Rating Stars (Click)	Cardiac Monitoring & Emergency Care		1	2	3	4
	Obtains 12 lead EKG
	Interpretation of rhythm strips
	Treatment of dysrythmias
	Use of rapid response teams
	Cardiac arrest/CPR
	O2 therapy & delivery
	Pulse oximetry
	Use of doppler
Rating Stars (Click)	IV Therapy		1	2	3	4
	Starting & maintaining peripheral Ivs
	Blood draw: venous
	Central line care
	Blood draw: central line
	Care & management of ports
	Care & management of PICC/Groshong/Hickman
	TPN & lipids
	Administration of blood/blood products
	Administration of chemotherapy
	Monitoring chemotherapy (does not initiate)
Rating Stars (Click)	Other		1	2	3	4
	Diabetes mellitus
	Blood Glucose Monitoring (BGM)
	Insulin administration
Rating Stars (Click)	Cardiac		1	2	3	4
	Assessment of heart sounds
	Pacemakers - permanent
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	Aneurysm
	Angina
	Angioplasty (pre/post)
	CHF
	Carotid endarterectomy
	Post MI
	Pre/post cardiac cath
	Pre/post cardiac surgery
Rating Stars (Click)	Use & Administration of the Following:		1	2	3	4
	Antiarrhythmic
	Antihypertensives
	Beta blockers
	Diuretics
	Nitrates
	Fibrinolytics/IIb IIIa inhibitors
Rating Stars (Click)	Respiratory		1	2	3	4
	Assessment of breath sounds
	Chest tubes (Emerson/Pleuravac)
	Interpretation of ABG
	Incentive spirometer
	Mechanical ventilation
	Oral suctioning
	Nasotracheal suctioning
	Tracheostomy care
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	COPD
	Pre/post thoracic surgery
	Thyroidectomy
	Pulmonary embolism
	Pulmonary edema
	Pneumothorax
	Pneumonia
	Inhalation injuries
	Tuberculosis
	Emphysema
	Asthma
Rating Stars (Click)	Use & Administration of the Following:		1	2	3	4
	Bronchodilators
	Steroids
	Expectorants
Rating Stars (Click)	Gynecology		1	2	3	4
	Endometriosis
	Gyn exam/pap
	Self breast exam
	Tubal ligation
	Ectopic pregnancy
	Mastectomy/lumpectomy
	Hysterectomy (vaginal or TAHBSO)
	Repair of cystocele/rectocele
	Pelvic inflammatory disease
	Abnormal uterine bleeding
Rating Stars (Click)	Neurology		1	2	3	4
	Glasgow coma scale
	Seizure precautions
	Assist with lumbar puncture
	Halo traction
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	CVA
	TIA
	Overdose
	Spinal cord injury/trauma
	TBI (Traumatic Brain Injury)
	Pre/post neuro surgery
	Cranial hemorrhage
	Delirium tremors
	Meningitis
	Neuromuscular diseases
Rating Stars (Click)	Use & Administration of the Following:		1	2	3	4
	Antiepileptics
	Corticosteroids
	Steroids
Rating Stars (Click)	Gastrointestinal		1	2	3	4
	NG tube insertion
	Management of small bore feeding tubes (Dobhoff, Keofeed)
	Jejunostomy tube
	PEG tube
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	Pancreatitis
	Hepatitis
	G.I. bleed
	Esophageal bleeding
	Bowel obstruction
	Bowel resection
	Gastric bypass
	Gastric banding
	Whipple procedure
	Transplants (specify)
	Colostomy/ileostomy
	Paralytic ileus
	E.R.C.P
Rating Stars (Click)	Use & Administration of the Following:		1	2	3	4
	Anticholinergics (antispas, bentyl or robinul)
	Cathartics
Rating Stars (Click)	Genitourinary/Renal		1	2	3	4
	Catheter insertion
	GU irrigations
	Nephrostomy tube
	Suprapubic tube
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	Hemodialysis
	T.U.R.P.
	Shunts and fistulas
	Nephrectomy
	Peritoneal dialysis
	Renal transplant
	Chronic/acute renal failure
Rating Stars (Click)	Orthopedic		1	2	3	4
	Total joint replacement
	Arthroscopic surgery
	Bucks extension
	Fasciotomy
	Fractures
	Spika cast/body cast
	Splints
	CPM
	TENS unit
	Cast care & removal
	Amputation
	Skeletal traction
	Ortho trauma
	Cervical fusion
	Laminectomy
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
Rating Stars (Click)	Other		1	2	3	4
	Care of patient with sepsis
	Oncology
	Chemotherapy
	Radiation therapy
	Radiation implants
	Inpatient hospice
	Suicide precautions
	Burn patients
	Additional Skills
	Leadership skills (team leader or charge nurse)
Rating Stars (Click)	Age Specific Competencies		1	2	3	4
	Newborn/neonate (birth-30 days)
	Infant (31 days-1 year)
	Toddler (ages 2-3 years)
	Preschool (ages 4-5 years)
	School age (ages 6-12 years)
	Adolescent (ages 13-21 years)
	Young adult (ages 22-39 years)
	Adult (ages 40-64 years)
	Older adult (ages 65-79 years)
	Elderly (ages 80+ years)