|
|
Nurse Practitioner
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)
|
Areas Worked
|
1
|
2
|
3
|
4
|
|
|
|
Emergency
|
|
|
|
|
|
|
|
Urgent Care
|
|
|
|
|
|
|
|
Private Practice
|
|
|
|
|
|
|
|
HMO
|
|
|
|
|
|
|
|
MD Office
|
|
|
|
|
|
|
|
Schools
|
|
|
|
|
|
|
|
Health Department
|
|
|
|
|
|
|
|
Ambulatory Clinic
|
|
|
|
|
|
|
|
Rural Health Clinic
|
|
|
|
|
|
|
|
Psychiatric Facility
|
|
|
|
|
|
|
|
Correctional Facility
|
|
|
|
|
|
|
|
Mobile Medical Unit
|
|
|
|
|
|
|
|
Corporate Worksite
|
|
|
|
|
|
|
|
Occupational Health
|
|
|
|
|
|
|
|
Rehabilitation
|
|
|
|
|
|
|
|
Nursing Home/ Long-term
Care Facility
|
|
|
|
|
|
|
|
Women's Health Clinic
|
|
|
|
|
|
|
|
Government Health Agency
|
|
|
|
|
|
|
|
Hospice/Palliative
Care
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Experience With
|
1
|
2
|
3
|
4
|
|
|
|
Diabetes
|
|
|
|
|
|
|
|
Contractures
|
|
|
|
|
|
|
|
Bedridden residents
|
|
|
|
|
|
|
|
Splinting of extremities
|
|
|
|
|
|
|
|
Local infiltration
|
|
|
|
|
|
|
|
Comprehensive physical
assessment
|
|
|
|
|
|
|
|
Acute disease condition
|
|
|
|
|
|
|
|
Differential diagnosis
|
|
|
|
|
|
|
|
Order, may perform, &
interpret screening & diagnostic test
|
|
|
|
|
|
|
|
Central line management
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Disorders – Emergencies
|
1
|
2
|
3
|
4
|
|
|
|
Anaphylaxis
|
|
|
|
|
|
|
|
Cardiac arrest
|
|
|
|
|
|
|
|
Seizures
|
|
|
|
|
|
|
|
Minor head injuries
|
|
|
|
|
|
|
|
Animal bites
|
|
|
|
|
|
|
|
Ingestions and poisonings
|
|
|
|
|
|
|
|
Overdose of sedative,
hypnotics, opiates
|
|
|
|
|
|
|
|
Snake bites
|
|
|
|
|
|
|
|
Minor burns
|
|
|
|
|
|
|
|
Shock
|
|
|
|
|
|
|
|
Open wounds
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Collaboration
|
1
|
2
|
3
|
4
|
|
|
|
Family, support system,
community resources
|
|
|
|
|
|
|
|
Consulting with Physicians
|
|
|
|
|
|
|
|
Consulting with Pharmacists
|
|
|
|
|
|
|
|
Consulting with Speech
Therapist
|
|
|
|
|
|
|
|
Consulting with Dietician
and Diet Aide
|
|
|
|
|
|
|
|
Consulting with
Occupational Therapist
|
|
|
|
|
|
|
|
Referral to Pastoral
Services
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Respiratory
|
1
|
2
|
3
|
4
|
|
|
|
Croup
|
|
|
|
|
|
|
|
Influenza
|
|
|
|
|
|
|
|
Tracheobronchitis
|
|
|
|
|
|
|
|
Bronchitis
|
|
|
|
|
|
|
|
COPD (chronic obstructive
pulmonary disease)
|
|
|
|
|
|
|
|
Asthma
|
|
|
|
|
|
|
|
URI (upper respiratory
infection)
|
|
|
|
|
|
|
|
Obstructive Sleep Apnea
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Pneumonia
|
1
|
2
|
3
|
4
|
|
|
|
Viral
|
|
|
|
|
|
|
|
Bacterial
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Sinusitis
|
1
|
2
|
3
|
4
|
|
|
|
Bacterial
|
|
|
|
|
|
|
|
Nonbacteria
|
|
|
|
|
|
|
|
Oxygen administration
|
|
|
|
|
|
|
|
Liquid oxygen
|
|
|
|
|
|
|
|
IPPB machine use
|
|
|
|
|
|
|
|
Tracheotomies
|
|
|
|
|
|
|
|
Interpret ABG (blood gases)
|
|
|
|
|
|
|
|
Intubations
|
|
|
|
|
|
|
|
Sputum Collection
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Cardiovascular System
|
1
|
2
|
3
|
4
|
|
|
|
Congestive heart failure
|
|
|
|
|
|
|
|
Chronic obstructive
pulmonary disease
|
|
|
|
|
|
|
|
Stasis ulcer of lower
extremities
|
|
|
|
|
|
|
|
Angina
|
|
|
|
|
|
|
|
Pericarditis
|
|
|
|
|
|
|
|
Coronary artery disease
|
|
|
|
|
|
|
|
Functional murmurs
|
|
|
|
|
|
|
|
Congenital heart disease
|
|
|
|
|
|
|
|
Hypertension
|
|
|
|
|
|
|
|
ASHD (arteriosclerotic
heart disease)
|
|
|
|
|
|
|
|
Dyslipidemia
|
|
|
|
|
|
|
|
PVD (peripheral vascular
disease)
|
|
|
|
|
|
|
|
Peripheral neuropathy
|
|
|
|
|
|
|
|
Interpreting 12 lead EKG’s
|
|
|
|
|
|
|
Rating Stars
(Click)
|
OB/GYN
|
1
|
2
|
3
|
4
|
|
|
|
Candida vaginitis
|
|
|
|
|
|
|
|
Dysmenorrhea
|
|
|
|
|
|
|
|
Abnormal pap smear findings
|
|
|
|
|
|
|
|
Pap smears
|
|
|
|
|
|
|
|
Trichomonal vaginitis
|
|
|
|
|
|
|
|
Atrophic vaginitis
|
|
|
|
|
|
|
|
Fibrocystic breast disease
|
|
|
|
|
|
|
|
Menopause
|
|
|
|
|
|
|
|
Intrapartum medications
|
|
|
|
|
|
|
|
Bartholin's cyst/abscess
|
|
|
|
|
|
|
|
Preparation for childbirth
|
|
|
|
|
|
|
|
Pregnancy - diagnosis and
referral
|
|
|
|
|
|
|
|
Pain relief in active phase
of labor
|
|
|
|
|
|
|
|
Medications in the third
stage
|
|
|
|
|
|
|
|
Dysfunctional uterine
bleeding
|
|
|
|
|
|
|
|
Medications in the
postpartum phase
|
|
|
|
|
|
|
|
Rh blood factor
|
|
|
|
|
|
|
|
Mastitis
|
|
|
|
|
|
|
|
Birth control methods
|
|
|
|
|
|
|
|
Prenatal care
|
|
|
|
|
|
|
|
Fetal well-being
|
|
|
|
|
|
|
|
Nausea and vomiting with
pregnancy
|
|
|
|
|
|
|
|
Pap smears
|
|
|
|
|
|
|
|
Pregnancy test kits
|
|
|
|
|
|
|
Rating Stars
(Click)
|
GI System
|
1
|
2
|
3
|
4
|
|
|
|
Constipation
|
|
|
|
|
|
|
|
Diarrhea (simple)
|
|
|
|
|
|
|
|
Acute gastroenteritis
|
|
|
|
|
|
|
|
Cholecystitis
|
|
|
|
|
|
|
|
Pyloric stenosis
|
|
|
|
|
|
|
|
Colic
|
|
|
|
|
|
|
|
Appendicitis
|
|
|
|
|
|
|
|
Naso-gastric tubes
|
|
|
|
|
|
|
|
Gastrostomy Care
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Skin
|
1
|
2
|
3
|
4
|
|
|
|
Warts
|
|
|
|
|
|
|
|
Basal cell carcinoma
|
|
|
|
|
|
|
|
Scabies
|
|
|
|
|
|
|
|
Impetigo
|
|
|
|
|
|
|
|
Diaper dermatitis
|
|
|
|
|
|
|
|
Acne
|
|
|
|
|
|
|
|
Folliculitis
|
|
|
|
|
|
|
|
Furuncles
|
|
|
|
|
|
|
|
Carbuncles
|
|
|
|
|
|
|
|
Herpes Simplex
|
|
|
|
|
|
|
|
Herpes Zoster
|
|
|
|
|
|
|
|
Malignant melanoma
|
|
|
|
|
|
|
|
Pityriasis Rosea
|
|
|
|
|
|
|
|
Contact dermatitis
|
|
|
|
|
|
|
|
Tinea corporis
|
|
|
|
|
|
|
|
Tinea pedis
|
|
|
|
|
|
|
|
Staph infections
|
|
|
|
|
|
|
|
Wound care
|
|
|
|
|
|
|
|
Single layer wound closure
|
|
|
|
|
|
|
|
Incision and drainage
|
|
|
|
|
|
|
|
Excisions
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Ears, Nose and Throat
|
1
|
2
|
3
|
4
|
|
|
|
Epistaxis
|
|
|
|
|
|
|
|
Otitis externa
|
|
|
|
|
|
|
|
Serous otitis media
|
|
|
|
|
|
|
|
Acute purulent otitis media
|
|
|
|
|
|
|
|
Allergic rhinitis
|
|
|
|
|
|
|
|
Pharyngitis
|
|
|
|
|
|
|
|
Oral candidiasis
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Eye
|
1
|
2
|
3
|
4
|
|
|
|
Conjunctivitis
|
|
|
|
|
|
|
|
Strabismus
|
|
|
|
|
|
|
|
Chalazion
|
|
|
|
|
|
|
|
Stye
|
|
|
|
|
|
|
|
Visual acuity
|
|
|
|
|
|
|
|
Fluorescein staining of
eyes
|
|
|
|
|
|
|
|
Audiometry
|
|
|
|
|
|
|
|
Tympanometry
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Musculoskeletal
|
1
|
2
|
3
|
4
|
|
|
|
Osteoporosis
|
|
|
|
|
|
|
|
Osteomyelitis
|
|
|
|
|
|
|
|
Rheumatoid arthritis
|
|
|
|
|
|
|
|
Juvenile diabetes
|
|
|
|
|
|
|
|
Gout
|
|
|
|
|
|
|
|
Minor sprains and strains
|
|
|
|
|
|
|
|
Osteoarthritis
|
|
|
|
|
|
|
|
Carpal tunnel syndrome
|
|
|
|
|
|
|
|
Scoliosis
|
|
|
|
|
|
|
|
Tendonitis
|
|
|
|
|
|
|
|
Bursitis
|
|
|
|
|
|
|
|
Muscular dystrophy
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Parasitic Infections
|
1
|
2
|
3
|
4
|
|
|
|
Pinworms
|
|
|
|
|
|
|
|
Ascariasis
|
|
|
|
|
|
|
|
Pediculosis
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Genitourinary System
|
1
|
2
|
3
|
4
|
|
|
|
Syphilis
|
|
|
|
|
|
|
|
Chlamydia
|
|
|
|
|
|
|
|
Herpes
|
|
|
|
|
|
|
|
Cystitis
|
|
|
|
|
|
|
|
Pyelonephritis
|
|
|
|
|
|
|
|
Urinary tract infection
|
|
|
|
|
|
|
|
Benign prostatic
hypertrophy
|
|
|
|
|
|
|
|
Vulvovaginitis
|
|
|
|
|
|
|
|
Hypospadias
|
|
|
|
|
|
|
|
Hydrocele
|
|
|
|
|
|
|
|
Gonococcal infections
|
|
|
|
|
|
|
|
Prostatitis
|
|
|
|
|
|
|
|
Catheter Care
|
|
|
|
|
|
|
|
Incontinence care-bowel
|
|
|
|
|
|
|
|
Dermal ulcers
|
|
|
|
|
|
|
|
Enemas/ Suppositories/
Fecal
|
|
|
|
|
|
|
|
Urine collection
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Nervous System
|
1
|
2
|
3
|
4
|
|
|
|
Vasovagal syncope
|
|
|
|
|
|
|
|
Migraine headaches
|
|
|
|
|
|
|
|
Multiple sclerosis
|
|
|
|
|
|
|
|
Headaches
|
|
|
|
|
|
|
|
Head injury
|
|
|
|
|
|
|
|
Tension
|
|
|
|
|
|
|
|
Anxiety
|
|
|
|
|
|
|
|
Parkinson’s
|
|
|
|
|
|
|
|
Alzheimer’s
|
|
|
|
|
|
|
|
Bell’s Palsy
|
|
|
|
|
|
|
|
TIA (transient ischemic
attacks)
|
|
|
|
|
|
|
|
Trigeminal neuralgia
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Endocrine
|
1
|
2
|
3
|
4
|
|
|
|
Type I diabetes mellitus
|
|
|
|
|
|
|
|
Type II diabetes mellitus
|
|
|
|
|
|
|
|
Graves disease
|
|
|
|
|
|
|
|
Addison's disease
|
|
|
|
|
|
|
|
Juvenile diabetes
|
|
|
|
|
|
|
|
Hypoglycemia
|
|
|
|
|
|
|
|
Hypothyroidism
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Hematological
|
1
|
2
|
3
|
4
|
|
|
|
Folic acid deficiency
anemia
|
|
|
|
|
|
|
|
Aplastic anemia
|
|
|
|
|
|
|
|
Iron deficiency
|
|
|
|
|
|
|
|
Sickle cell anemia
|
|
|
|
|
|
|
|
Pernicious anemia
|
|
|
|
|
|
|
|
Hemoglobinmeter
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Psychosocial
|
1
|
2
|
3
|
4
|
|
|
|
Depression
|
|
|
|
|
|
|
|
Suicide
|
|
|
|
|
|
|
|
Obesity
|
|
|
|
|
|
|
|
Grief
|
|
|
|
|
|
|
|
Anxiety
|
|
|
|
|
|
|
|
Anorexia
|
|
|
|
|
|
|
|
Bulimia
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Drug Therapy
|
1
|
2
|
3
|
4
|
|
|
|
Prescription
|
|
|
|
|
|
|
|
Over the counter (OTC)
|
|
|
|
|
|
|
|
Herbal drugs
|
|
|
|
|
|
|
|
Knowledge of pharmacology
|
|
|
|
|
|
|
|
Knowledge of
pharmacokinetics
|
|
|
|
|
|
|
|
Knowledge of drug
interactions
|
|
|
|
|
|
|
|
Knowledge of side effects
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Knowledge of potential
adverse reactions
|
1
|
2
|
3
|
4
|
|
|
|
Allergic reactions
|
|
|
|
|
|
|
|
Anaphylaxis reaction
|
|
|
|
|
|
|
|
TPN/Lipid Management
|
|
|
|
|
|
|
|
Management/Titration of IV
Therapies
|
|
|
|
|
|
|
|
IV/PO Antibiotic Therapy
and understanding of cultures
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Dispensing Medication
|
1
|
2
|
3
|
4
|
|
|
|
Monitoring drug therapy
|
|
|
|
|
|
|
|
Management of controlled
substances
|
|
|
|
|
|
|
|
Injections
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Non-Pharmacologic
Interventions
|
1
|
2
|
3
|
4
|
|
|
|
Medical nutrition therapy
|
|
|
|
|
|
|
|
Exercise
|
|
|
|
|
|
|
|
Cessation of substance
abuse (alcohol, tobacco)
|
|
|
|
|
|
|
|
Mental health issues
(stress management, depression)
|
|
|
|
|
|
|
|
Obesity management
|
|
|
|
|
|
|
|
Tube Feeding Management
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Miscellaneous
|
1
|
2
|
3
|
4
|
|
|
|
Public health and health
promotion
|
|
|
|
|
|
|
|
Research
|
|
|
|
|
|
|
|
Quality assurance
|
|
|
|
|
|
|
|
Leadership and teaching
skills
|
|
|
|
|
|
|
|
Legal and ethical issues
|
|
|
|
|
|
|
|
Confidentiality
|
|
|
|
|
|
|
|
Cultural awareness
|
|
|
|
|
|
|
|
Self evaluation to improve
patient care
|
|
|
|
|
|
|
|
Continuing education
|
|
|
|
|
|
|
|
Working within scope of
practice
|
|
|
|
|
|
|
|
Discharge planning /
collaboration
|
|
|
|
|
|
|
|
Suturing
|
|
|
|
|
|
|
|
Cell biopsy
|
|
|
|
|
|
|
|
Starting IV
|
|
|
|
|
|
|
|
Casting and splinting
|
|
|
|
|
|
|
|
Radiographic interpretation
(initial)
|
|
|
|
|
|
|
|
Informed consent
|
|
|
|
|
|
|
|
Explanation to
patient/family
|
|
|
|
|
|
|
|
Documentation
|
|
|
|
|
|
|
|
Venipuncture
|
|
|
|
|
|
|
|
Ultrasounds
|
|
|
|
|
|
|
Rating Stars
(Click)
|
Programs
|
1
|
2
|
3
|
4
|
|
|
|
OSHA (Occupational Safety
and Health Administration)
|
|
|
|
|
|
|
|
Medicare and Medicaid
|
|
|
|
|
|
|
|
CLIA waiver (Clinical
Laboratory Improvement Amendments)
|
|
|
|
|
|
|
|
TJC (The Joint Commission)
|
|
|
|
|
|
|
|
HEDIS (Health Plan Employer
Data and Information Set)
|
|
|
|
|
|
|
|
DQIP (Diabetes Quality
Improvement Program)
|
|
|
|
|
|
|
|
HIPAA (Health Insurance
Portability & Accountability Act)
|
|
|
|
|
|
|
|
HCAHPS
|
|
|
|
|
|
|
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 APPROPRIATE CARE
|
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)
|
|
|
|
|
|