CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE RISK MANAGER 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)  Self-assessment Related to my Clinical Specialty 1 2 3 4  
I work in an area that is consistent with my training and experience   
My competencies (including experience, training, education and skills) are
consistent with the needs of my assigned patients and/or patient care unit  		 
I understand the risk of caring for patients within my clinical specialty   
 When I am floated or asked to cross-cover, I ensure that my competencies and experience are appropriate for the assignment  
I am provided with or request orientation whenever I am assigned to a different
clinical care unit or different level of care 		 
I obtain education and training on an ongoing basis to maintain my
competencies in my clinical specialty 		 
I decline an assignment if my competencies are not consistent with patient
needs 		 
Rating Stars (Click) Self-assessment Related to Scope of Practice 1 2 3 4  
 I know my Nurse Practice Act and read it at least annually to ensure I
understand the legal scope of practice in my state 		 
I decline to perform a requested service that is outside my legal scope of
practice and immediately notify my supervisor or the director of nursing 		 
 I contact the risk management department or the legal department regarding
patient or practice issues, if necessary 		 
I contact the Board of Nursing and request an opinion or position statement on
nursing practice issues, if necessary 		 
Rating Stars (Click) Self-assessment Related to Patient Assessment 1 2 3 4  
 I assess and document the following upon admission, with a change in
treatment, or with a change in a patient’s condition or response to treatment: 		 
 Presenting problem(s)  
 Fall risk  
Co-morbidities affecting the patient’s status  
Patient’s understanding of his/her condition and plan of
treatment/care 		 
Mobility status, including the use of mobility aids  
Medications  
Elopement/abduction risk  
Skin/wound status including any wounds or lesions  
Pain management  
Restraint use  
Behaviors  
Cognition  
Nutrition/hydration  
Vital signs  
Lab values  
Rating Stars (Click) Self-assessment Related to Patient Monitoring  1 2 3 4  
Vital signs, blood pressure, oxygen saturation  
Blood sugar  
INR/clotting times/bruising  
Blood and diagnostic test results (notifying the practitioner of
abnormal results) 		 
Clinical signs of bleeding or hemorrhage  
Effectiveness of pain management  
Signs of infection and/or inflammation  
Restraint protocol compliance  
Nutritional intake  
Oral and intravenous fluid intake and output  
Output – urine, stool, wound drainage  
Wound status – measurement, treatment and response to treatment  
 Behaviors  
Cognition  
Patient concerns/complaints  
Change in condition  
Response to medication/treatment, including change in behavior,
cognition and potential increased risk for falls 		 
Patient safety – current environment  
Rating Stars (Click) Self-assessment Related to Treatment and Care 1 2 3 4  
Timely implementation of approved/standardized protocols  
Timely contacting the practitioner to obtain orders  
Timely implementation of practitioner orders  
Medication administration, as ordered (i.e., ensuring correct
medication, patient, dose, route, and time; checking the reason for
administering medications; and noting if the problem was lessened
or alleviated, etc.) 		 
Patient/family education related to treatment and verification of their
understanding 		 
Practitioner notification of change in condition/symptoms/patient
concerns and practitioner’s response and/or orders 		 
Practitioner notification of complications and adverse response to
medication or treatment and practitioner’s response and/or orders 		 
Supervision of non-professional caregivers  
Provision of nutrition and hydration (assisting patient as needed)  
Oversight/scheduling of referrals/tests/diagnostic procedures  
Tracking of test results/consultation reports  
Practitioner notification of test/consultation results and
practitioner’s response and/or orders 		 
Participation in accurate and complete hand-offs between assigned
caregivers, units and shifts 		 
Practitioner notification of delays and issues encountered in
carrying out orders 		 
Follow-up on delays and issues in obtaining test or test results  
Invoking of nursing and medical chains of command if there is a
delay in response from practitioner or significant concern with
practitioner action taken 		 
Practitioner notification of patient refusal of recommended
healthcare (e.g., assessments, diagnosis and/or treatment
interventions including medications) 		 
Reporting of any patient incident, injury or adverse outcome and
subsequent treatment/response 		 
Rating Stars (Click) Self-assessment Related to Patient Care Equipment and Supplies 1 2 3 4  
I ensure that emergency and required patient care equipment is readily
available and in good working order 		 
I check all equipment before each use to ensure that it functions properly  
I explain procedures and treatments to patients, including what touching they can anticipate during assessment, monitoring and treatment  
I honor the patient’s rights throughout the episode of care  
I include a chaperone when indicated if intimate touching is required for the patient’s treatment  
I monitor the patient care environment to ensure patient safety  
I perform all required monitoring, assessment and reporting activities  
I provide oral and written reports of broken/malfunctioning equipment to all appropriate parties  
I refrain from harsh physicial touching or movement with patients at all times  
I refrain from personal relationships with patients/families  
I remain aware of the need for ensuring a safe patient care environment,
including unobstructed hallways, properly secured entrances and exits, and restricted access to hazardous substances 		 
I report broken/malfunctioning equipment, remove it from patient care use and obtain an appropriate replacement  
I sequester broken/malfunctioning equipment that was involved in a patient incident to preserve its condition at the time of the event.  
I speak to patients, families and staff in a respectful and dignified manner  
Rating Stars (Click) Self-assessment Related to Documentation Practices 1 2 3 4  
I document contemporaneously and never make a late entry unless it is
appropriately labeled and is necessary for safe continued patient care 		 
I never remove any portion of the patient’s health information record  
I never alter a record in any way  
I refrain from subjective comments, including comments about colleagues
and other members of the patient care team 		 
I do not remove patient health records (paper or electronic) from the patient care unit, nor do I make entries from home or other inappropriate locations  
If provided with a laptop, electronic pad or electronic PDA, I do not permit any other person access to that equipment and never share my passwords/
access codes 		 
If I have documentation concerns, I contact the risk manager or legal counsel for assistance prior to making an entry about which I am unsure  
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 Specific Competencies 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)