REGISTERED NURSE SKILLED NURSING CHECKLIST

		REGISTERED NURSE SKILLED NURSING 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)	General Skills		1	2	3	4
	Advanced directives
	Awareness of HCAHPS
	Patient/family teaching
	Discharge planning
	UR/medicare review
	Lift/transfer devices
	Specialty beds
	Restrictive devices (restraints)
	End of life care/palliative care
	Automated Medication Dispensing System, Pyxis, Omnicell, or other
	National Patient Safety Goals
	Accurate patient identification
	Effective communication
	Awareness of patient rights
	Interpretation & communication of lab values
	Medication administration
	Labeling (medications & specimens)
	Medication reconciliation
	Anticoagulation therapy
	Pain assessment & management
	Infection control
	Universal precautions
	Isolation
	Minimize risk for falls
	Prevention of pressure ulcers
Rating Stars (Click)	Cardiac		1	2	3	4
	Assessment of heart sounds
	Identification of arrhythmias (rate/rhythm)
	Pacemakers/AID’s
	Cardiac arrest/CPR
	Hypertension
	Pre/post MI
	CHF
	Post cardiac surgery
	Fluid & electrolyte imbalances
Rating Stars (Click)	Medication Administration		1	2	3	4
	Anticoagulants
	Antiarrhythmics
	Beta blockers
	Nitroglycerin
	Diuretics
Rating Stars (Click)	Respiratory		1	2	3	4
	Assessment/auscultation of lung sounds
	Establishing an airway
	Chest PT
	Incentive spirometry
	Supplemental oxygen (cannula, facemask)
	Tracheostomy care
	Suctioning (tracheostomy & nasotracheal)
	Nebulizer use
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	Pneumonia
	Asthma
	COPD
	Emphysema
Rating Stars (Click)	Use & Administration of:		1	2	3	4
	Bronchodilators
	Expectorants
	Corticosteroids
Rating Stars (Click)	Neurology		1	2	3	4
	Assessment of neuro signs
	Seizure precautions
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	TBI (Traumatic Brain Injury: history of)
	Seizure activity
	Spinal cord injury
	Stroke (CVA)
	Multiple sclerosis
	Alzheimer’s disease
	Parkinson’s disease
	ALS (Amyotrophic Lateral Sclerosis)
Rating Stars (Click)	Use & Administration of:		1	2	3	4
	Antiseizure medications
	Antiemetics
	Laxatives
	Enemas
	Bowel prep
Rating Stars (Click)	Gastrointestinal		1	2	3	4
	NG tube (insertion/removal)
	Long term feeding tubes (dobhoff/keofeed)
	Gastrostomy tube
	Tube feedings
	Monitoring input/output
	Foley catheter insertion/removal
	GU irrigations
	Nephrostomy tube
	Suprapubic catheter
	Ileo conduit
	Use of bladder scan equipment
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	Colostomy/ileostomy
	GI bleed
	Feeding devices/adaptive equipment
	Dietary restrictions
	GT/PEG feedings
Rating Stars (Click)	Use & Administration of:		1	2	3	4
	Antiemetics
	Laxatives
	Enemas
	Bowel prep
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	Shunts and fistulas
	Straight catheterizations
	Incontinence/bladder training
	Chronic renal failure/dialysis
	Peritoneal dialysis
Rating Stars (Click)	Orthopedic		1	2	3	4
	Total joint replacement
	Arthroscopic surgery
	Cast care
	Pulse/CMS checks
	Suture/staple removal
	Prosthesis application
	Standard extremity braces
Rating Stars (Click)	Care of Patient with:		1	2	3	4
	Amputation
	Stump wrapping
	Laminectomy
	Assistive devices
	CPM machines
Rating Stars (Click)	IV Therapy		1	2	3	4
	Start & maintain Ivs
	Blood draw: venous
	Central line care (PICC)
	Blood draw: central line PICC
	Care & management of ports
	Infusion pumps
	Administration of blood/blood products
Rating Stars (Click)	Skin		1	2	3	4
	Wound care/surgical
	Wound care/medical
	Dressing changes
	Skin assessment
	Wound vac
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/neonate (birth-30 days)
	Infant (31 days-1 year)
	Toddler (2-3 years)
	Preschool (ages 4-5 years)
	School age (ages 6-12 years)
	Adolescents (ages 13-21 years)
	Young adult (ages 22-39 years)
	Adults (ages 40-64 years)
	Older adult (ages 65-79 years)
	Elderly (ages 80+ years)