CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE HOSPICE 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) WORK SETTINGS 1 2 3 4  
Home Hospice  
Inpatient Hospice   
Pediatric Hospice  
Home Health/Hospice Setting  
Rating Stars (Click) ASSESSMENT 1 2 3 4  
Intake Assessment   
Assessment Interview   
Physical Exam  
Coping Status   
Environmental Status  
Rating Stars (Click) PLAN OF CARE 1 2 3 4  
Set Goals with Pt/Family   
Collaborate with Other Team Members   
Ensure Continuity of Care  
Rating Stars (Click) SYMPTOM MANAGEMENT 1 2 3 4  
Urgent Assessment of Symptoms   
Reduce Symptoms to Level Acceptable to Pt.   
Report Symptoms/Management to Provider   
Treat Underlying Cause   
Severity Scale   
Management of Nausea  
Management of Constipation   
Management of Fatigue   
Anorexia/Cachexia   
Restlessness   
Educate Family on Symptom Management  
Rating Stars (Click) PAIN MANAGEMENT 1 2 3 4  
Identify Source of Pain   
Pain Severity   
PAINAD Scale for Non Verbal Patient   
Reduce Pain to Level Acceptable to Patient  
WHO 3 Step Ladder   
Non-Pharmacologic Management of Pain   
Pharmacologic Management of Pain   
Effects of Pharmacologic Treatment   
Nociceptive/Neuropathic/Mixed Pain   
Management of Nociceptive Pain   
Management of Neuropathic Pain  
Educate Family on Pain Management  
Rating Stars (Click) WOUND CARE 1 2 3 4  
Positioning Techniques   
Bed/Support Surface Selection   
Pressure Ulcer Staging/Management   
Response to Treatment   
Evaluate Factors that Impede Healing   
Educate Family on Positioning/Shearing  
Rating Stars (Click) PEDIATRICS 1 2 3 4  
Developmentally Appropriate Assessment   
Parental/Sibling Support   
Pediatric Support Team Collaboration  
Rating Stars (Click) MEDICATION ADMIN 1 2 3 4  
Equianalgesic Conversion Formula   
Titration of opioids   
IV Pump Management   
Evaluate Effectiveness of Medications   
Family Management of Medications   
Disposal of Medications  
Rating Stars (Click) AFTER DEATH 1 2 3 4  
Facility Family/Cultural Rituals/Rites   
Patient Care after Death   
Coordinate Mortuary Services   
Bereavement Services  
Rating Stars (Click) COMPLIANCE 1 2 3 4  
Scope and Frequency of Services   
Medicare/State Regulations for Hospice   
Document Progression of Decline   
DME Authorization & Documentation of Need/Order   
OASIS-C  
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS 1 2 3 4  
Identify Source of Suffering   
Palliative Care Philosophy   
Patient/Family Directs Goals of Care   
Maximize Quality of Life   
Cultural Diversity  
Supervision of Ancillary Staff  
National Patient Safety Goals/Core Measures   
Fall Risk Assessment/Prevention  
Infection Prevention     
Isolation Precautions   
Interpretation and Communication of Lab Values  
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)  
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) EMR 1 2 3 4  
Epic   
Cerner   
Eclipsys   
Allscripts   
McKesson  
Meditech   
Other Computerized System   
Computerized Physician Order Entry   
Bar Coding for Medication Administration  
  EMR Conversion
   
CERTIFICATIONS     Expiry Date :   
BLS  
CHPN  
ACHPN  
CHPPN  
  Other: Specify     
  Other: Specify