CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE AMBULATORY
   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) General Patient Care 1 2 3 4  
Admit and Assess Patients  
Advance Directives   
Collect Appropriate Data   
Discharge Teaching   
Preoperative Teaching   
Patient Prep   
Computerized Documentation  
Rating Stars (Click) Cardiovascular 1 2 3 4  
Assess Heart Tones  
Bedside Tele Monitoring  
Interpretation of Coagulation Studies   
Perform Pulses/Circulation Checks  
Pre/Post Op Care Pacemaker  
Rating Stars (Click) Pulmonary 1 2 3 4  
Assess Breath Sounds  
Apply Oxygen  
Interpret ABGs   
Thoracentesis   
Oximetry   
Rating Stars (Click) Neurology 1 2 3 4  
Assess Neurological Signs  
Epidurals  
Selective Nerve Root Blocks   
Level of Consciousness   
Rating Stars (Click) GI 1 2 3 4  
Insertion/Monitoring NG Tubes  
Assessment/Patient Care Continued  
Flexible Sigmoidoscopy  
Hemorrhoid Banding   
Liver Biopsy   
Paracentesis   
Lap Band Surgery  
Rating Stars (Click) GU 1 2 3 4  
Bladder Biopsy   
Cystoscopy   
Urethral Dilation  
Nephrostomy   
Kidney Biopsy  
Suprapubic Catheter   
Prostate Biopsy   
Rating Stars (Click) Endocrine 1 2 3 4  
Care of Diabetic Patient  
Diabetic Teaching  
Rating Stars (Click) ENT and Mouth 1 2 3 4  
Prosthondontics – Restorative Dentistry  
Mouth Biopsy   
Myringotomy   
Maxillofacial Prosthetics   
Nose Biopsy   
Thyroid Aspirate Biopsy   
Fiberoptic Laryngoscopy   
Tonsilectomy   
Rhinoplasty   
Rating Stars (Click) Wounds/Integument 1 2 3 4  
Application of Burn Dressings   
Application of Dressing  
Debridement of Wound   
Wound Care  
Rating Stars (Click) OB/GYN 1 2 3 4  
Electrodesiccation and Curettage (ED&C)  
Nipple Reconstruction   
Rating Stars (Click) Musculoskeletal 1 2 3 4  
Arthrocentesis  
External Hardware and Pin Care   
Arthroscopy   
Open Reduction and Internal Fixation  
Closed Reduction and Internal Fixation  
Trigger Point Injections   
Rating Stars (Click) Plastics 1 2 3 4  
Liposuction  
Plastic Surgery   
Cosmetic   
Rating Stars (Click) General Medications/Therapeutic Interventions 1 2 3 4  
Administer IM and SQ Meds  
Administer Inhalation Medications  
Administer PO Medications   
Bladder Irrigation and Instillation   
Needleless Systems   
Chemotherapy   
Rating Stars (Click) IV Therapy 1 2 3 4  
Infusion Pumps  
Peipheral IV Insertion   
Syringe Pumps  
Vascular Access Devices Care/Maintenance  
Administer IV Medications  
Rating Stars (Click) Oxygen Administration 1 2 3 4  
Ambu-Bug   
Nasal Cannula   
Non-ReBreather Mask  
Pulse Oximetry  
Venti Mask  
Face Mask   
Rating Stars (Click) Nutritional Therapy 1 2 3 4  
Lipids  
TPN  
Procalamine  
Enteral Administration  
Rating Stars (Click) Pain Management/Anesthesia 1 2 3 4  
Inplantable Narcotic Pump Re ll   
Moderate Sedation  
Epidural   
Spinal   
Local   
General   
Axillary Block  
Bier Block   
Rating Stars (Click) Blood 1 2 3 4  
Blood and Blood Products  
Albumin   
Rating Stars (Click) General Procedures/Equipment 1 2 3 4  
Apply Immobilizers (clavicle, knee, etc.)  
Assist with Code Resuscitation  
Assist with Lumbar Puncture   
Laser  
Dermabrasion   
Drain Removal   
Incision and Drainage  
NGT Insertion  
Patch Test   
Punch Biopsy  
Procedure Set Up  
Procedures/Equipment Continued  
Remove External Fixators With Pin   
Scissor Biopsy   
Scrub  
Screw-Hardware Removal   
Set-up Assist Suturing   
Staple Removal   
Straight/Foley Cath Female  
Straight/Foley Cath Male  
Suture Removal   
TENS (Transcutaneous Elec. Nerve Stimulator)   
Use of Doppler    
Rating Stars (Click) Specimen Collections 1 2 3 4  
Venipuncture  
Clean Catch Urine  
Sterile Urine Collection   
Stool   
Sputum  
Butter y Stick  
Central Line Draw  
Rating Stars (Click) Clinical Settings 1 2 3 4  
Surgi-Center  
Out Patient Clinic  
Age Group Experience Continued  
Physician O ce   
Ambulatory Surgery Clinic  
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  
EpicNewborn/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)  
Rating Stars (Click) Joint Commission 1 2 3 4  
National Safety Goals  
“Do Not Use” Abbreviations and Terms