CYNET_SYSTEMS_MAIN_LOGO.gif   SOCIAL WORKER 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) Knowledge of Assessment Process 1 2 3 4  
Psychosocial assessment (social history, living situation, career, hobbies, support systems, decision making, communication difficulties, flexibility, prolonged mental illness / emotional Problems, lack of community / caregiver support, family discord, ability to deal with loss)  
Health history, review of system and physical examination  
Development of problem list  
Development and revision of care plan  
Assesses response to treatment  
Establish and revises goals  
Conducts complete Initial Evaluation  
Rating Stars (Click) Documentation Skills (accurate, timely, complete and legible 1 2 3 4  
Initial assessment and plan  
Skilled visit notes  
Physician’s orders  
Discharge Summary  
Rating Stars (Click) Adheres to Plan of Care 1 2 3 4  
Review POC prior to care  
Performs services as ordered  
Documents according to POC  
Communicates / coordinates if appropriate  
Rating Stars (Click) Knowledge of Medical / State regulations 1 2 3 4  
Criteria for participation  
Skilled reimbursable visit  
Rating Stars (Click) Effective Case Coordination 1 2 3 4  
Reports & documents key information to physician, supervisor & case manager  
Team member (RN, PT, OT, ST,LPN/LVN  
Community resources  
Attends / participates in case conferences as required  
Rating Stars (Click)  Infection Control 1 2 3 4  
Hand-washing  
Protective equipment  
Exposure Plan  
Rating Stars (Click) Communication  Abilities 1 2 3 4  
Develop and maintain communication with people on complex matters, issues and ideas, and/or in complex situations  
Rating Stars (Click) Personal and People Development 1 2 3 4  
Develop oneself and contribute to the development of others  
Rating Stars (Click) Patient Education 1 2 3 4  
Determines learning needs  
Sets objectives  
Develops & implements teaching plan  
Evaluates effectiveness of teaching  
Revises teaching plan  
Documents patient response  
Rating Stars (Click) Quality Improvement & Service 1 2 3 4  
Contribute to the improvement of services & maintain quality in own work and encourage others to do so  
Rating Stars (Click) Health Protection & Well Being 1 2 3 4  
Implement aspects of a protection plan and review its effectiveness  
High risk intervention / patient vulnerability or safety risk  
Monitor and maintain health, safety and security of self and others  
Provide crisis intervention  
Rating Stars (Click) Care Planning 1 2 3 4  
Assess complex health and well being needs and develop, monitor and review care plans to meet those needs  
Rating Stars (Click) Knowledge and InformationResources 1 2 3 4  
Organize knowledge and information resources and provide information to meet needs  
Demonstrates respect for patient/family confidentiality  
Documentation Skills (accurate, timely, complete and legible)  
Counseling for long range planning and decision making  
Rating Stars (Click) Equality and Diversity 1 2 3 4  
Promote equality and value diversity  
Rating Stars (Click) Experience in all or any of the following: 1 2 3 4  
Medical Social Work  
School Social Work  
Clinical Social Work  
Social Work-Admin/management  
Social work-case manager  
International Social Work  
Social Work-Children & Families  
Social Work in Acute Psychiatric Hospital  
Forensic Social Work  
Employment/Occupational Social Work  
Social Work- Community Organizer  
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)