CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE ACUTE REHAB
   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  
Home Health  
Nursing Home  
Outpatient Clinic  
Pediatric Rehab  
Acute Rehab Hospital  
Rehab Unit in Hospital  
Rating Stars (Click) Neuro 1 2 3 4  
Cerebral Vascular Accident  
Coma Patients  
Head Trauma  
Spinal Cord Injury  
Parkinson’s Disease  
Traumatic Brain Injury  
Neuromuscular Disease  
Post Craniotomy  
Bowl/Bladder Programs  
Rating Stars (Click) Ortho 1 2 3 4  
Arthritis Programs  
Back Syndrome  
Cervical Traction  
Continuous Passive Motion Machine N/A  
Gait Training  
Hand Injury  
Hip Fractures  
Care of Patient with Halo  
Hot/Cold Packs  
Mobilization Techniques  
Neck Injuries  
TMJ Dysfunction  
Total Hip Replacement  
Total Knee Replacement  
Rating Stars (Click) Pulmonary 1 2 3 4  
Assessment of breath sounds  
Chest Physiotherapy  
Oximetry  
Nasal cannula  
Face Mask  
Portable O2 tank  
Nasotracheal Suctioning  
Tracheal Suctioning  
Care of patient w/Mechanical Vent  
COPD  
Rating Stars (Click) Pediatrics 1 2 3 4  
Cerebral Palsy  
Activities of Daily Living  
Learning Disabilities  
Orthotics  
Spina Bifida  
Autism  
AK Prosthetics  
Amputees  
BK Prosthetics  
Bracing/Joint Immobilization  
Resting Splints  
Casts/Check for Circulation  
Upper Extremity Prosthetics  
Rating Stars (Click) Nutritional Requirements 1 2 3 4  
Thickened Liquids  
Minimal  
Thick  
Extra Thick  
Pudding Thick  
NG Tubes  
Peg Tubes  
Rating Stars (Click) Restraints 1 2 3 4  
4pt  
Shoulder Strap  
Hand Mitts  
Wrist  
Ankle  
Pelvic Strap  
Rating Stars (Click) Other 1 2 3 4  
Ability to evaluate and assign Functional Independence Score  
AIDS Patients  
Burn Management  
Cardiac Rehabilitation  
Function Capacity Evaluation  
Geriatrics  
Manual Therapy  
Massage Therapy  
Muscle Stimulation  
Pain Management/Giving Meds  
Physical Capacity  
Pulmonary Rehab  
Sterilization Technique  
TENS  
Wound Debridement/Dressing Change  
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)