CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE NICU 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) PATIENT TYPES 1 2 3 4  
Neonates < 28 Weeks  
Neonates 29 - 34 Weeks   
Neonates > 34 Weeks  
Rating Stars (Click) WORK SETTINGS 1 2 3 4  
Level II NICU  
Level III NICU  
Level IV NICU  
Rating Stars (Click) CARDIOVASCULAR 1 2 3 4  
Cardiac Surgery - Pre-op   
Cardiac Surgery - Immediate Post-op  
Congenital Heart Disease/Defects  
CHF/Pulmonary Edema  
Hemodynamic Instability  
Rating Stars (Click) PULMONARY 1 2 3 4  
Bronchopulmonary Dysplasia  
Diaphragmatic Hernia  
Fresh Tracheostomy  
Meconium Aspiration   
Persistent Pulmonary Hypertension  
Pneumonia  
Respiratory Distress Syndrome/Failure  
Interpretation of ABGs  
Assist with Intubation/Extubation  
Endotracheal Suctioning  
Chest Tube Placement and Management  
Modes of Ventilation (AC/PC/SIMV/CPAP/BiPAP)  
High Frequency Ventilation   
Inhaled NO  
ECMO  
Rating Stars (Click) NEUROLOGIC 1 2 3 4  
Ballard/Dubowitz  
Reflexes Based on Gestational Age  
Hydrocephalus  
Intraventricular Hemorrhage  
Meningocele/Myelomeningocele  
Neonatal Abstinence Score/Syndrome  
Seizures  
Rating Stars (Click) GASTROINTESTINAL 1 2 3 4  
Colostomy/Ileostomy  
Gastroschisis/Omphalocele  
GI Bleeding  
Necrotizing Enterocolitis  
Post Abdominal Procedure  
Rating Stars (Click) FEEDINGS 1 2 3 4  
Breast Milk Handling/Storage  
Breast Pump  
Gavage Feedings  
NG/OG/NJ Tube Placement and Management  
Rating Stars (Click) RENAL/ENDOCRINE/GENETIC 1 2 3 4  
Circumcision Care  
Genetic Disorders  
Hypo/Hyperglycemia  
Infant of Diabetic Mother  
Malformations of the GU Tract/Kidney  
Phototherapy  
Renal Failure  
Rating Stars (Click) INFECTIOUS DISEASES 1 2 3 4  
Neonatal Sepsis  
Septic Work Up  
Assist with Lumbar Puncture  
Rating Stars (Click) MEDICATIONS 1 2 3 4  
Calculation of Neonatal Dosages  
Antibiotics/Antivirals  
Anticonvulsants  
Immunizations  
Digoxin  
IV Vasopressors  
Prostaglandin  
Bronchodilators  
Steroids  
Caffeine  
Surfactant  
Automated Medication Dispensing (i.e. Pyxis, Omnicell)  
Rating Stars (Click) IV THERAPY 1 2 3 4  
Administration of Blood/Blood Products  
Central Line Catheter/Dressings  
Management of UAC/UVC Lines  
Radial Arterial Lines  
Start IVs  
Rating Stars (Click) CARDIAC MONITORING & EMERG. RESPONSE 1 2 3 4  
Attend High Risk Deliveries  
Preparation for Transport  
Transport Neonate  
Rhythm Interpretation  
Dysrhythmia Management  
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS 1 2 3 4  
National Patient Safety Goals/Core Measures  
Bereavement/Postmortem Care  
Neonatal Skin Care  
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  
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)  
CERTIFICATIONS     Expiry Date :   
BLS  
NRP  
PALS  
S.T.A.B.L.E  
NCC Certification - RNC-NIC  
  Other: Specify  
  Other: Specify