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REGISTERED NURSE
MEDICAL SURGICAL CHECKLIST
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NAME
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LAST 4 OF SSN
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DATE
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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.
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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.
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Proficiency Scale:
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1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
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Rating Stars (Click)
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CARDIAC
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1
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2
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3
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4
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Angina
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Post Acute MI
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Congestive Heart Failure
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Post Cardiac Cath
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Post Cardiac Surgery
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Aneurysm
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Carotid
Endarterectomy
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Post Vascular Surgery
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Post Cardiac Transplant
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Rating Stars
(Click)
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PULMONARY
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1
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2
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3
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4
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Pneumonia
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COPD
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Tuberculosis
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Pulmonary Embolism
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Tracheostomy
Management
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CPAP/BiPAP
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Interpretation of Arterial
Blood Gases
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Post Lung Transplant
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Rating Stars
(Click)
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NEUROLOGICAL &
PSYCHIATRIC
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1
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2
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3
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4
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Stroke Scale
Assessment
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Traumatic Brain
Injury
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CVA
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Post Craniotomy
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Seizure Disorders
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Spinal Cord Injuries
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Mood Disorders
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Substance Withdrawal
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Rating Stars
(Click)
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ORTHOPEDICS
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1
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2
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3
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4
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Circulation/Skin
Checks
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Continuous Passive Motion
Devices
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Ambulation Assistive
Devices
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Prosthetics
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Cast Care
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Pin Care
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Traction
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Total Joint
Replacement
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Amputation
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Rating Stars
(Click)
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GASTROINTESTINAL
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1
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2
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3
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4
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Bariatrics
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Feeding Tubes
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GI Bleeding
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Bowel Obstruction
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GI Surgery
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Liver Disease
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Pancreatitis
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Post Liver Transplant
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Post Pancreas Transplant
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Rating Stars
(Click)
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RENAL/GENITOURINARY
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1
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2
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3
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4
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Arteriovenous
Fistula/Shunt
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3 Way Catheter &
Bladder Irrigation
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Suprapubic Catheter
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Renal Failure
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Peritoneal Dialysis
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GU Surgery
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Nephrostomy Tubes
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Renal Transplant
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Management Pre/Post
Hemodialysis
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Gyn Surgery
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Rating Stars
(Click)
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ENDOCRINE METABOLIC
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1
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2
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3
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4
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Diabetes Type I
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Diabetes Type II
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Blood Glucose
Monitoring
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IV Insulin Protocols
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Management of
Hypoglycemia
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Indwelling Insulin
Pumps
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Pituitary Disorders
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Rating Stars
(Click)
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ONCOLOGY
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1
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2
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3
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4
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Chemotherapy
Administration
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Radiation Therapy
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Medical Oncology
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Surgical Oncology
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Radiation Implants
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Bone Marrow Transplant
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Rating Stars
(Click)
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MEDICATIONS
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1
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2
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3
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4
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Antiarrhythmics
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Anticoagulants (IV, oral,
& injection)
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Anti-Depressants
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Anti-Hypertensives
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Anti-Psychotics
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Benzodiazepines
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Emergency Medications
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Epidural Analgesia
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Inhaled Medications
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Insulin
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Narcotics/Opioid
Analgesics (IV, oral, & injection)
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Nitrates (Oral &
Topical)
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Non-Opioid Analgesics (IV,
Oral, & Injection)
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Oral Hypoglycemics
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Patient Controlled
Analgesia
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Procedural Sedation
Administration
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Reversal Agents
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Steroids (IV, Oral,
Inhaled)
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Automated Medication
Dispensing (i.e. Pyxis, Omnicell)
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Rating Stars
(Click)
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IV THERAPY
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1
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2
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3
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4
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Starting IVs
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Central Line Blood
Draws
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Central Line/Implanted
Line Care
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TPN & Lipids
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Blood Product
Administration
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Monitoring of Chemotherapy
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Rating Stars
(Click)
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CARDIAC MONITORING &
EMERG. RESPONSE
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1
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2
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3
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4
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Placement of Telemetry
Leads
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Rhythm Interpretation
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Dysrhythmia
Management
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Obtain 12 Lead EKG
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Use of Rapid Response
Teams
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Rating Stars
(Click)
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PROFESSIONAL KNOWLEDGE AND
SKILLS
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1
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2
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3
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4
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National Patient Safety
Goals/Core Measures
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Fall Risk
Assessment/Prevention
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Pressure Ulcer Risk
Assessment/Prevention
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Restraints/Use of Least
Restrictive Device
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Patient/Family
Teaching
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Age
Specific/Population-Based Care
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Isolation Precautions
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Infection Prevention
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Pain Assessment &
Management
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Charge Experience
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Interpretation and
Communication of Lab Values
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Wound Care /Wound Vac
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Specialty Beds
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Rating Stars
(Click)
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EMR
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1
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2
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3
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4
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Epic
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Cerner
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Eclipsys
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McKesson
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Meditech
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Other Computerized
System
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Computerized Physician
Order Entry
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Bar Coding for Medication
Administration
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EMR Conversion
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Rating Stars
(Click)
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AGE APPROPRIATE CARE
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1
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2
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3
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4
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Newborn/Neonatal (birth –
30 days)
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Infant (30 days-1 year)
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Toddler (1-3 years)
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Preschool (3-5 years)
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School Age Children (5-12
years)
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Adolescent (12-17 years)
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Young Adults (18-44 years)
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Middle Adults (45-64
years)
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Older Adults (>65
years)
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MY EXPERIENCE IS
PRIMARILY IN:
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Unit
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No. of Years
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Unit
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No. of Years
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BURN
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POST PARTUM
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CRITICAL UNIT
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LABOR & DELIVERY
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PACU
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NEWBORN NURSERY
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NEUROLOGY
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LEVEL II NICU
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TELEMETRY
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LEVEL III NICU
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MEDICAL
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PICU
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SURGICAL
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PEDIATRICS
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ONCOLOGY
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OB/GYN
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ORTHOPEDICS
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PSYCHIATRY
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OPERATING ROOM
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RRT
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EMERGENCY ROOM
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CRT
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TRAUMA CENTER
LEVEL 1
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COMMUNITY ER
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RURAL ER
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CERTIFICATIONS
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Expiry Date :
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BLS
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ACLS
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Telemetry Certificate
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ONS Chemo/Biotherapy
Certification
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Other Chemo Certification
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ACLS
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