CYNET_SYSTEMS_MAIN_LOGO.gif   PT / PTA 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) ADULT ( Orthopedic ) 1 2 3 4  
Neck Injuries / Surgeries  
Back Injuries / Surgeries   
Hip Fractures / Injuries  
Hip Fractures / Injuries  
Knee Injuries  
Total Knee Replacement  
Upper Extrem Joint Replacements  
Shoulder Injuries  
Degen. Joint Disease / Arthritis  
Hand Injuries  
Temporomandibular Joint (TMJ)  
Post Operative Care  
Amputations   
Rating Stars (Click) Neurologic 1 2 3 4  
Stroke Rehabilitation  
Cognitive Disorders  
Head Trauma  
Spinal Cord Injury  
Functional Splinting  
Adaptive Equipment-Wheelchair  
Neuromuscular Diseases  
Multiple Sclerosis  
Rating Stars (Click) ADULT ( Prosthetics / Orthotics ) 1 2 3 4  
Upper Extremity Prosthetics  
Above Knee Prosthetics  
Below Knee Prosthetics  
Rating Stars (Click) Sports Medicine 1 2 3 4  
LIDO  
Nautilus / Eagle  
Taping  
Rating Stars (Click)  Prosthetics / Orthotics 1 2 3 4  
Other  
Chest PT  
Cardiac Rehab  
ICU Procedures  
CCU Procedures  
SICU Procedures  
Burn Management  
Work Hardening - Work Site Eval  
Work Capacity Eval  
Rating Stars (Click) Procedures / Treatments 1 2 3 4  
Ankle / Foot Orthosis  
Slings  
Splints - Wrist / Hand  
CPM Machine  
Hydrotherapy  
Whirlpool   
Hubbard Tank  
Therapeutic Pool  
TENS  
Electrical Stimulation  
Ultrasound   
Cryotherapy  
Massage  
Diathermy  
Acupressure  
Spinal Mobilization  
Extremity Mobilization  
Myofacial Release  
Craniosacral Techniques  
Cervical Traction  
Lumbar Traction  
Activities of Daily Living  
Gait Training  
transfers  
Sports Medecine  
Athletic Injuries  
Biodex  
Cybex  
Orthotron  
Rating Stars (Click) OTHERS 1 2 3 4  
Functional Capacity Eval  
Muscle Energy Techniques  
Activities of Daily Living  
Universal Precautions  
Skilled Nursing Documentation  
Medicare B  
State Healthcare  
Skilled Nursing Documentation  
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)