CYNET_SYSTEMS_MAIN_LOGO.gif   PHYSICAL THERAPY 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) Work Settings 1 2 3 4  
Adult/adult ICU  
Children’s hospital  
General acute care  
Home health care  
Outpatient neuro  
Outpatient ortho  
Pediatrics/PICU  
Psychiatric hospital  
Rehabilitation hospital  
School setting  
Early intervention  
Skilled care facility  
Subacute  
Rating Stars (Click) Orthopedics 1 2 3 4  
Upper extremities  
Arthritis programs  
Back syndrome  
Cervical injuries  
Chronic fatigue syndrome  
Fibromyalgia  
Halo traction  
Hand injury  
Hip fracture  
Kyphoplasty  
Manual therapy  
Mobilization techniques  
Pelvic fracture  
Postpolio syndrome  
Shoulder injuries  
TMJ dysfunction  
Total hip/total knee  
Total joint replacement  
Total shoulder/CPM  
Rating Stars (Click) Neurologic 1 2 3 4  
ALS  
Brain tumors  
Cerebral palsy  
Multiple sclerosis  
Muscular dystrophy  
Polio/post polio syndrome  
Spinal cord injury  
Adaptive equipment  
Functional splinting  
Neurodevelopmental testing (NDT)  
Head trauma  
Glasgow coma scale  
Stroke rehabilitation  
Wheelchair prescription  
Rating Stars (Click) Pediatrics 1 2 3 4  
Activities of daily living  
Adaptive  
Developmental disability  
Equipment assessment  
Individualized education programs  
Neurodevelopmental testing (NDT)  
Orthotics  
Sequencing testing  
Rating Stars (Click) Sports Medicine 1 2 3 4  
Biodex  
Bracing/joint  
Cybex  
Immobilization  
Lido  
Medical expenses (Norwegian)  
Nautilus/eagle  
Orthotron/kinetron  
Stabilization techniques  
Swiss ball  
Taping/strapping  
Rating Stars (Click) Prosthetics/Orthotics 1 2 3 4  
Dynamic splints  
LE prosthetics  
Protonics  
Removeable rigid dressings  
Serial casting  
Static splints  
UE prosthetics  
Rating Stars (Click) Modalities 1 2 3 4  
Anodyne  
Biofeedback  
Edema massage  
Fluidotherapy  
Iontophoresis  
JOBST compression pump  
Muscle stimulation  
Paraffin bath  
Phonophoresis  
TENS  
Therapeutic pool  
Ultrasound  
Rating Stars (Click) Other 1 2 3 4  
Burn management  
Cardiac rehabilitation  
Chest physical therapy  
DME ordering  
FIM scoring  
Job task analysis  
Lymphedema management  
OASIS assessment for home care  
Obstetrics in physical therapy  
Tone management/spasticity  
Wheelchair ordering for SCI patients  
Work capacity evaluation  
Work hardening  
Wound care  
  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  
  Computerized Charting:  
Cerner  
EPIC  
McKesson  
Meditech  
  National Patient Safety Goals:  
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  
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)