OCCUPATIONAL_THERAPY_SELF_ASSESSMENT

		Occupational Therapy Self Assessment
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)	Work Settings		1	2	3	4
	General acute care
	Adult/adult ICU
	Pediatrics/PICU
	Children’s hospital
	Hand therapy
	Home health care
	Outpatient neuro
	Outpatient ortho
	Psychiatric hospital
	Rehabilitation hospital/inpatient rehabilitation unit
	Skilled care facility
	School setting
	Early intervention
	Subacute
Rating Stars (Click)	Orthopedics		1	2	3	4
	Hand injury
	Total joint replacement/upper extremities
	Lower back/spinal surgeries
	Arthritis programs
	Soft tissue injuries
	Knee injuries & total knee replacement
	Hip fractures & total hip replacement
	Mobilization techniques
	Prosthetics/amputations
Rating Stars (Click)	Neurologic		1	2	3	4
	Alzheimers/dementia
	Degenerative diseases of the CNS
	Multiple sclerosis
	Parkinson’s disease
	Spinal cord injury
	Adaptive equipment
	Neurodevelopmental testing (NDT)
	Wheelchair evaluation
	Stroke acute
	Stroke rehabilitation
	Functional splinting
	Traumatic brain injury
Rating Stars (Click)	Pediatric Assessments		1	2	3	4
	Neurodevelopmental testing
	Developmental screening
	Sensory-motor testing
	Visual perceptual testing
	Feeding/swallowing/oral motor
	Seating & positioning assessment (i.e. w/c)
Rating Stars (Click)	Other Assessments		1	2	3	4
	Physical capacity evaluation
	Home assessments/home accessibility
	Activities of daily living
	Driving evaluation
	Cognitive/perception
Rating Stars (Click)	Treatment Approaches		1	2	3	4
	ADL
	Cognitive retraining
	Community re-entry
	Energy conservation/work simplification techniques
	Functional transfer training
	Home safety
	Lymphedema management
	Orthotics/Prosthetics training
Rating Stars (Click)	Treatment Approaches - cont.		1	2	3	4
	Patient, family & staff training
	PNF
	SI
	Therapeutic exercises/activities
	Work hardening
	Splinting
	Neurodevelopmental testing (NDT)
	Incontinence management
Rating Stars (Click)	Modalities		1	2	3	4
	Anodyne
	Biofeedback
	Electrical stimulation
	Feeding techniques
	Fluidotherapy
	Oral motor facilities
	Paraffin bath
	TENS
	Therapeutic pool
	Ultrasound
Rating Stars (Click)	Prosthetics/Orthotics		1	2	3	4
	UE prosthetics
	Static splints
	Dynamic splints
	Serial casting
Rating Stars (Click)	Other		1	2	3	4
	Burn management
	Cardiac rehabilitation
	Cognitive retraining
	Computer skills
	FIM scoring
	Geriatrics
	Group dynamics
	IEP skills
	Inservice education
	Job task analysis
	Therapeutic media
	Knowledge of payment sources
	Medicare
	Medicaid
	MDS
Rating Stars (Click)	General Skills		1	2	3	4
	Patient/family teaching
	Patients in isolation
	Patients in restraints
	Initial evaluation
	Lift/transfer devices
	Specialty beds
	End of life care/palliative care
Rating Stars (Click)	Computerized Charting:		1	2	3	4
	Cerner
	EPIC
	McKesson
	Meditech
Rating Stars (Click)	National Patient Safety Goals:		1	2	3	4
	Accurate patient identification
	Effective communication
	Pain assessment & management
	Infection control
	Universal precautions
	Care of patients in isolation
	Minimize risk of falls
	Prevention of pressure ulcers
Rating Stars (Click)	EMR		1	2	3	4
	Epic
	Cerner
	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)
Rating Stars (Click)	Please list any Additional Skills:
1
2
3
4
	Additional training:
1
2
3
4
	Additional equipment:
1
2
3
4