PCT_SKILLS_CHECKLIST

		PCT 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 Patients:		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)	Unit Activity		1	2	3	4
	Identifying Unusual Incidents on the Unit that Require Reporting
	Locating and Using Appropriate Reference Materials: Hospital, Patient Care and
	Charging for Patient Care Items
	Completing Risk Management Reports as Needed
	Obtaining Needed Supplies and Equipment
	Reporting and Following up on Faulty Equipment and Supplies
	Using Telephone System
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)