CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE MEDICAL SURGICAL 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  
Angina   
Post Acute MI   
Congestive Heart Failure  
Post Cardiac Cath   
Post Cardiac Surgery   
Aneurysm   
Carotid Endarterectomy   
Post Vascular Surgery   
Post Cardiac Transplant  
Rating Stars (Click) PULMONARY 1 2 3 4  
Pneumonia   
COPD   
Tuberculosis   
Pulmonary Embolism   
Tracheostomy Management   
CPAP/BiPAP   
Interpretation of Arterial Blood Gases   
Post Lung Transplant  
Rating Stars (Click) NEUROLOGICAL & PSYCHIATRIC 1 2 3 4  
Stroke Scale Assessment   
Traumatic Brain Injury   
CVA   
Post Craniotomy   
Seizure Disorders  
Spinal Cord Injuries   
Mood Disorders   
Substance Withdrawal  
Rating Stars (Click) ORTHOPEDICS 1 2 3 4  
Circulation/Skin Checks   
Continuous Passive Motion Devices   
Ambulation Assistive Devices   
Prosthetics   
Cast Care   
Pin Care   
Traction   
Total Joint Replacement   
Amputation  
Rating Stars (Click) GASTROINTESTINAL 1 2 3 4  
Bariatrics   
Feeding Tubes   
GI Bleeding   
Bowel Obstruction   
GI Surgery   
Liver Disease   
Pancreatitis   
Post Liver Transplant   
Post Pancreas Transplant  
Rating Stars (Click) RENAL/GENITOURINARY 1 2 3 4  
Arteriovenous Fistula/Shunt   
3 Way Catheter & Bladder Irrigation   
Suprapubic Catheter   
Renal Failure   
Peritoneal Dialysis   
GU Surgery   
Nephrostomy Tubes   
Renal Transplant   
Management Pre/Post Hemodialysis   
Gyn Surgery  
Rating Stars (Click) ENDOCRINE METABOLIC 1 2 3 4  
Diabetes Type I   
Diabetes Type II   
Blood Glucose Monitoring   
IV Insulin Protocols  
Management of Hypoglycemia   
Indwelling Insulin Pumps   
Pituitary Disorders  
Rating Stars (Click) ONCOLOGY 1 2 3 4  
Chemotherapy Administration   
Radiation Therapy  
Medical Oncology   
Surgical Oncology   
Radiation Implants   
Bone Marrow Transplant  
Rating Stars (Click) MEDICATIONS 1 2 3 4  
Antiarrhythmics   
Anticoagulants (IV, oral, & injection)   
Anti-Depressants  
Anti-Hypertensives   
Anti-Psychotics   
Benzodiazepines   
Emergency Medications   
Epidural Analgesia   
Inhaled Medications   
Insulin   
Narcotics/Opioid Analgesics (IV, oral, & injection)   
Nitrates (Oral & Topical)   
Non-Opioid Analgesics (IV, Oral, & Injection)   
Oral Hypoglycemics   
Patient Controlled Analgesia   
Procedural Sedation Administration   
Reversal Agents   
Steroids (IV, Oral, Inhaled)   
Automated Medication Dispensing (i.e. Pyxis, Omnicell)  
Rating Stars (Click) IV THERAPY 1 2 3 4  
Starting IVs   
Central Line Blood Draws   
Central Line/Implanted Line Care   
TPN & Lipids   
Blood Product Administration   
Monitoring of Chemotherapy  
Rating Stars (Click) CARDIAC MONITORING & EMERG. RESPONSE 1 2 3 4  
Placement of Telemetry Leads  
Rhythm Interpretation   
Dysrhythmia Management   
Obtain 12 Lead EKG   
Use of Rapid Response Teams  
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS 1 2 3 4  
National Patient Safety Goals/Core Measures   
Fall Risk Assessment/Prevention   
Pressure Ulcer Risk Assessment/Prevention   
Restraints/Use of Least Restrictive Device  
Patient/Family Teaching   
Age Specific/Population-Based Care   
Isolation Precautions   
Infection Prevention   
Pain Assessment & Management   
Charge Experience  
Interpretation and Communication of Lab Values   
Wound Care /Wound Vac  
Specialty Beds  
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  
  EMR Conversion
         
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)  
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    
CERTIFICATIONS     Expiry Date :   
BLS  
ACLS  
Telemetry Certificate  
ONS Chemo/Biotherapy Certification  
Other Chemo Certification  
ACLS