CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE LONG TERM CARE 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) CARDIAC 1 2 3 4  
Use of cardiac monitors  
Assessment of heart sounds  
Cardiac Arrest  
CPR  
Care of patients with CHF  
Atropine administration  
Digoxin administration  
Dopamine administration  
Inderal administration  
Lidocaine administration  
Rating Stars (Click) GENITOURINARY 1 2 3 4  
Fluid Balance  
Foley Catheter Insertion  
Ileostomy  
GU Irrigations  
Nephrostomy Tube  
Rating Stars (Click) ENDOCRINE 1 2 3 4  
Blood Glucose Checks  
Insulin Administration  
Care of patients with Diabetes  
Rating Stars (Click) GASTROINTESTINAL 1 2 3 4  
NG tube care and feedings  
Gastrostomy tube care and feedings  
Colostomy Care  
Assessment of Bowel Sounds  
Rating Stars (Click) LEADERSHIP/PATIENT CARE 1 2 3 4  
Taking Charge   
Admission Procedures  
Discharge Procedures  
Patient Education  
Patient Care Plans  
Rating Stars (Click) MEDICATIONS/IV THERAPY 1 2 3 4  
Medication Calculation  
Reconstitution  
Oral Administration  
Eye Administration  
IM Administration  
SQ Administration  
Rectal Administration  
Starting IV’s  
IV Medication Administration  
Central Line Care  
Rating Stars (Click) NEUROLOGY 1 2 3 4  
Assessment of Neurological Status  
Seizure Precautions  
Care of a patient with a CVA  
Care of a patient with Alzheimer’s  
Care of patients with Spinal Cord Injury  
Decadron Administration  
Dilantin Administration  
Phenobarbital Administration  
Valium Administration  
Rating Stars (Click) ORTHO/SKIN 1 2 3 4  
Assessment of skin  
Wound Care and Treatments  
Use of special pressure relief devices  
Care of pts with a total hip replacement  
Care of pts with a total knee replacement  
Crutch Walking  
Rating Stars (Click) RESPIRATORY 1 2 3 4  
Pulse Oximetry  
Oxygen Administration via nasal cannuia  
Oxygen Administration via face mask  
Principles of chest percussion  
Care of patients with ventilator  
Care of patients with COPD  
Care of patients with ARDS  
Care of patient with a Tracheotomy  
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 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)