REGISTERED NURSE HOME HEALTH

		REGISTERED NURSE HOME HEALTH
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)	CARDIOVASCULAR		1	2	3	4
	ACS/Post MI
	Heart Failure
	Post Cardiac Surgery
	Cardiac Auscultation (Rate/Rhythm)
	Peripheral Pulse/Circulation Checks
Rating Stars (Click)	PULMONARY		1	2	3	4
	Asthma
	COPD
	Pneumonia
	Lung Cancer
	Pulmonary Emboli
	Auscultate Lung Sounds
	Oxygen Administration
	Oxygen Safety
	Oro/Nasotracheal Suctioning
	CPAP/BiPAP
	Ventilator Management (Specify):
Rating Stars (Click)	NEUROLOGICAL		1	2	3	4
	CVA
	Alzheimer's Disease/Dementia
	Parkinson's
	Degenerative Neurologic Disorders (ALS, MS, etc.)
	Brain Tumor
	Brain Injury
	Para/Quadriplegia
	Seizure Disorder
	Level of Consciousness/Neuro Changes
Rating Stars (Click)	ORTHOPEDICS		1	2	3	4
	Joint Replacement
	DVT Prophylaxis/Recognition
	Incision Checks
	Staple Removal
	Fractures
	Cast/Brace
	Amputation
	Arthritis
	Assistive Equipment/Lift Devices
	In Home PT/INR (Specify):
Rating Stars (Click)	GASTROINTESTINAL		1	2	3	4
	Nutritional Assessment
	Colostomy/Ileostomy Management
	Fecal Incontinence/Diarrhea
	Bowel Obstruction
	GI Bleed
	Post GI Surgery
	Hepatitis Liver Failure
	NG Tubes
	Feeding Tubes
	Feeding Pumps (Specify):
	Drainage Devices
Rating Stars (Click)	RENAL/GENITOURINARY		1	2	3	4
	Hemodialysis
	AV Fistula/Shunt
	Peritoneal Dialysis
	Post Bladder Surgery
	Post Prostate Surgery
	Urostomy
	Urinary Incontinence
	Bladder Catheter Insertion/Maintenance
	Suprapubic Catheter Insertion/Maintenance
Rating Stars (Click)	ENDOCRINE/METABOLIC		1	2	3	4
	Diabetes
	Hyper/Hypoglycemia
	Diabetic Skin Assessment
	Cushing's / Addison's Disease
	Thyroid Disease
	Insulin Pumps
	Glucometers
Rating Stars (Click)	WOUND/SKIN CARE		1	2	3	4
	Braden Scale
	Pressure Ulcer Prevention
	Pressure Ulcer Staging
	Pressure Ulcer Management
	Burns
	Wound Care
	Wound Cultures
	Wound Vac
Rating Stars (Click)	ONCOLOGY		1	2	3	4
	Risk for Infection
	Symptom Management
	Side Effects of Treatment
	Terminal Disease
Rating Stars (Click)	INFECTIOUS DISEASE		1	2	3	4
	MRSA
	VRE
	C. Difficile
	HIV
	Tuberculosis
	Isolation Precautions
Rating Stars (Click)	PHLEBOTOMY/IV THERAPY		1	2	3	4
	Peripheral Venipuncture for Labs
	Start Ivs
	Peripheral Ivs
	PICC/CVP Lines
	Venous Access Ports
	Infusion Pump Set up and Management
	Specify Infusion Pump Type:
Rating Stars (Click)	PSYCHIATRIC		1	2	3	4
	Cognitive Disorders
	Mood Disorders
	Schizophrenia/Psychotic Disorders
	Medication Compliance
Rating Stars (Click)	WOMEN'S HEALTH/MATERNAL-INFANT CARE		1	2	3	4
	Pregnancy Related Complications
	Fetal Heart Tones
	Contractions
	Post Partum Mother/Baby Visit
	Newborn Care
	Phototherapy
	Breast Feeding Support
Rating Stars (Click)	PEDIATRICS		1	2	3	4
	Growth and Development
	Respiratory Distress Syndrome
	Bronchopulmonary Dysplasia
	Cystic Fibrosis
	Muscular Dystrophy
	Spina Bifida
	Spinal Surgery
	Sickle Cell Disease
	Trach Care/Suctioning
	Ventilator Management
	Ventilator Type (Specify):
Rating Stars (Click)	PAIN MANAGEMENT		1	2	3	4
	Verbal/Nonverbal Pain Scales
	Response to Pain Management Interventions
	PCA Pump
	Epidural Cath/Site Monitoring/Pump
	Non-Pharmacologic Pain Measures
Rating Stars (Click)	PALLIATIVE AND END OF LIFE CARE		1	2	3	4
	Palliative Symptom Management
	Pain Management/Response
	Family Support/Teaching
	After Death Protocols
Rating Stars (Click)	MEDICATIONS		1	2	3	4
	Alzheimer's Medications
	Antiarrhythmics
	Antibiotics/Antivirals
	Anti-Depressants
	Anti-Hypertensives
	Anti-Psychotics
	Anti-Seizure Medications
	Benzodiazepines
	Calculation of Pediatric Dosages
	Coumadin
	Diuretics
	Enoxaparin
	Inhaled Medications
	Nebulizer Medications
	Insulin
	Opioid and Non-Opioid Analgesics
	Oral Chemotherapy
	Oral Hypoglycemics
	Oral & Topics Nitrates
	Rivaroxaban
	Sedative/Hypnotics
	Steroids
Rating Stars (Click)	HOME HEALTH		1	2	3	4
	Intake/Admissions
	Case Manager
	Case Load - Pts/Day(specify)
	Supervise LVNs/HHAs
	Medicare/Medicaid
	Long/Short Term Disability
	Private Insurance
	Telephonic Assessments
	Management of Complaints
	APS Reports
	OASIS
	Diagnosis Coding
	Document Plan of Care
	Clinical Assessment Documentation
Rating Stars (Click)	PROFESSIONAL KNOWLEDGE AND SKILLS		1	2	3	4
	National Patient Safety Goals/Core Measures
	Safety Assessment
	Fall Assessment and Prevention
	Patient/Family Teaching
	Age Specific/Population Based Care
Rating Stars (Click)	EMR		1	2	3	4
	Allscripts
	Cerner
	Epic
	HomeCare Home Base
	McKesson
	Meditech
	Other Computerized Documentation System
	EMR Conversion
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)