CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE OB
   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 RIGHTS 1 2 3 4  
Communicates and obtains information while respecting the rights and privacy and confidentiality
of information 		 
Involves the patient and family and respects their role in determining the nature of care to be
provided, including Advanced Directives 		 
Complies with nursing staff responsibility include in the hospital policy related to Organ Donation  
Meets patient and families needs regarding communication, including interpreter services  
Provides accurate information to patient and families in a timely manner  
Rating Stars (Click) LABOR AND DELIVERY 1 2 3 4  
Assess cervical dilation  
Assess labor status  
Speculum examination  
Obtaining vaginal/cervical cultures  
Application of external ECG/TOCO EFM  
Application of internal ECG  
Interpretation of external/internal ECG  
Assisting with insertion of IUPC  
Conducting NST/BSST  
IV insertion  
Pitocin Titration for induction/augmentation  
Assist with epidural  
Assist/monitor amnioinfusion  
Assist with scalp pH test  
Assist with vacuum delivery  
Assist with forceps delivery  
Assist with vaginal delivery  
Circulate for cesarean section delivery  
Emergency cesarean section set up  
Assist with twin deliveries  
Assist with breech  
Management of D&C  
Management of fetal demise/stillborn  
Adoption procedures  
Management of diabetic mother  
Rating Stars (Click) Procedures for the following 1 2 3 4  
Diabetic mother  
PIH  
Pre-eclamptic  
Preterm labor  
Prolapsed cord  
Abruption  
Placenta previa  
Retained placenta  
Herpes  
Uterine prolapse  
Hemorrhage  
Shoulder dystocia  
DIC  
Accretia  
Episiotomy  
Delivery table set-up  
Rating Stars (Click) MEDICATIONS 1 2 3 4  
Magnesium  
Pitocin  
Terbutaline  
Antibiotics  
Narcotics  
Hemabate  
Methergine  
Narcan  
Insulin  
Heparin  
Rating Stars (Click) MATERNITY 1 2 3 4  
Oobtain cord blood gas  
Postpartum care  
Nipple care  
Episiotomy care  
PIH  
Pre-eclamptic  
Postpartum hemorrhage  
Care of newborn  
Breastfeeding  
Bottle feeding  
Infant formulas  
D10W  
PKU Testing  
Stabilize/admit to nursery   
Care of newborn with anomaly  
Heel sticks/dorsal sticks  
Blood glucose monitoring  
Phototherapy  
Set up/care of newborn receiving phototherapy  
Set up/assist with circumcision  
Discharge of mother/baby  
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)