CYNET_SYSTEMS_MAIN_LOGO.gif   PHYSICIAN ASSISTANT 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) Disorders-Emergencies 1 2 3 4  
Anaphylaxis  
Cardiac arrest  
Minor head injuries  
Ingestions and poisonings  
Seizures  
Animal bites  
Overdose of sedative, hypnotics, opiates  
Snake bites  
Minor burns  
Shock  
Open wounds  
Rating Stars (Click) Respiratory: 1 2 3 4  
Croup  
Tracheobronchitis  
COPD (chronic obstructive
pulmonary disease) 		 
Pneumonia  
Bacterial  
URI (Upper respiratory
infection) 		 
Influenza  
Bronchitis  
Nonbacterial  
Asthma  
Viral  
Rating Stars (Click) Cardiovascular system cont’d 1 2 3 4  
Stasis ulcer of lower extremities  
Pericarditis  
Functional murmurs  
Congestive heart failure  
Hypertension  
Chronic obstructive pulmonary disease  
Angina  
Coronary artery disease  
Congenital heart disease  
Rating Stars (Click) OB/GYN 1 2 3 4  
Nausea and vomiting with pregnancy  
Candida vaginitis  
Abnormal pap smear findings  
Atrophic vaginitis  
Menopause  
Preparation for childbirth  
Pain relief in active phase of labor  
Medications in the third stage  
Rh blood factor  
Medications in the Post Partum phase  
Pre-natal care  
Fetal well-being  
Dysmenorrhea  
Pap smears  
Trichomonal Vaginitis  
Fibrocystic breast disease  
Bartholin’s cyst/ abscess  
Pregnancy-diagnosis and referral  
Intrapartum medications  
Dysfunctional uterine bleeding  
Mastitis  
Birth control methods  
Rating Stars (Click) GI system: 1 2 3 4  
Constipation  
Irritable bowel syndrome  
Hiatal hernia  
Hepatitis  
Cholecystitis  
Appendicitis  
Pyloric stenosis  
Duodenal ulcer  
Hemorrhoids  
Acute gastroenteritis  
Diarrhea (simple)  
Rating Stars (Click) Skin: 1 2 3 4  
Warts  
Scabies  
Diaper dermatitis  
Folliculitis  
Carbuncles  
Herpes zoster  
Pityriasis Rosea  
Tinea corporis  
Tinea pedis  
Contact dermatitis  
Malignant melanoma  
Herpes simples  
Furuncles  
Acne  
Impetigo  
Basal skin carcinoma  
Rating Stars (Click) Ears, Nose, and Throat: 1 2 3 4  
Epistaxis  
Serous otitis media  
Allergic rhinitis  
Acute purulent Otitis media  
Otitis externa  
Pharyngitis  
Oral candidiasis  
Rating Stars (Click) Eye: 1 2 3 4  
Conjunctivitis  
Chalazion  
Stye  
Strabismus  
Rating Stars (Click) Musculoskeletal: 1 2 3 4  
Osteoporosis  
Muscular dystrophy  
Osteomyelitis  
Bursitis  
Rheumatoid arthritis  
Tendonitis  
Juvenile diabetes  
Scoliosis  
Gout  
Carpal tunnel syndrome  
Minor sprains and strains  
Osteoarthritis  
Rating Stars (Click) Parasitic Infections: 1 2 3 4  
Pinworms  
Pediculosis  
Ascariasis  
Rating Stars (Click) Genitourinary System: 1 2 3 4  
Syphilis  
Herpes  
Pyelonephritis  
Benign prostatic hypertrophy  
Hypospadias  
Gonococcal infections  
Prostatitis  
Hydrocele  
Vulvovaginitis  
Urinary tract infection  
Cystitis  
Chlamydia  
Rating Stars (Click) Nervous System: 1 2 3 4  
Vasovagal syncope  
Migraine headaches  
Headaches  
Multiple sclerosis  
Tension  
Head injury  
Migraine  
Anxiety  
Parkinson’s  
Alzheimer’s  
Stroke  
Bell’s Palsy  
TIA (transient ischemic attacks)  
Multiple sclerosis  
Trigeminal neuralgia  
Rating Stars (Click) Endocrine: 1 2 3 4  
Type I diabetes mellitus  
Type II diabetes mellitus  
Addison’s disease  
Graves disease  
Juvenile diabetes  
Hypoglycemia  
Hypothyroidism  
Rating Stars (Click) Hematological: 1 2 3 4  
Folic acid deficiency anemia  
Aplastic anemia  
Iron deficiency  
Pernicious anemia  
Sickle cell anemia  
Rating Stars (Click) Psychosocial: 1 2 3 4  
Depression  
Obesity  
Anxiety  
Bulimia  
Anorexia  
Grief  
Suicide  
Rating Stars (Click) Miscellaneous: 1 2 3 4  
Cell biopsy  
Starting IV  
Suturing  
Casting and splinting  
Rating Stars (Click) EMR: 1 2 3 4  
Allscripts  
Epic  
Meditech  
McKesson  
Homecare Home base  
Cerner  
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)