CYNET_SYSTEMS_MAIN_LOGO.gif   SPEECH LANGUAGE PATHOLOGIST SKILLS 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) Work Settings 1 2 3 4  
Acute care  
Children’s hospital  
Daily treatment center  
Home health care  
Inpatient acute rehab  
Neonatal intensive care  
Outpatient/outpatient community re-entry  
Pediatrics  
Psychiatric hospital  
Private practice  
School setting  
Early intervention  
Skilled nursing facility  
Rating Stars (Click) Patient Populations 1 2 3 4  
Geriatrics  
Hearing impaired  
Learning disabilities  
Pediatrics/school age  
Progressive neurologic disease  
Trachs/ventilators  
Transient Ischemic Attach (TIA)  
Traumatic brain injury  
Voice/laryngectomy  
Rating Stars (Click) Assessment Tools 1 2 3 4  
Boston assessment of severe aphasia  
Boston diagnostic aphasia examination  
Minnesota test for differential diagnosis of aphasia  
Informal testing  
Porch index of communicative abilities  
Reading comprehension battery for aphasia  
Ross information processing assessment-geriatric  
Western aphasia battery  
Bedside swallow evaluation  
Blue dye test  
Cervical auscultation  
Fiber endoscopic evaluation study  
Modified barium swallow study  
Rehab Institute of Chicago evaluation of communication  
Augmentative devices  
Pure tone screening  
Rating Stars (Click) Types of Disorders 1 2 3 4  
Aphasia  
Apraxia  
Autism  
Cleft palate  
CVA/stroke  
Fluency  
Dementia/alzheimers  
Dysarthria  
Dysphagia  
Hearing loss  
Learning disabilities  
Traumatic brain injury  
Rating Stars (Click) Treatment 1 2 3 4  
Augmentative devices  
Behavior modification  
Cognitive training  
Community re-entry  
Computer  
Co-treatment  
Rating Stars (Click) Treatment - cont. 1 2 3 4  
Group  
Individual  
Safety awareness  
Total communication  
Vital stimulation  
Dysphagia across the age-spectrum  
Rating Stars (Click) Regulations 1 2 3 4  
FIMS  
Medi-Cal  
Medicare  
Omnibus budget reconciliation  
RUG levels  
Rating Stars (Click) General Skills 1 2 3 4  
Patient/family teaching  
Patients in isolation  
Patients in restraints  
Initial evaluation  
Lift/transfer devices  
Specialty beds  
End of life care/palliative care  
Rating Stars (Click) Computerized Charting: 1 2 3 4  
Cerner  
EPIC  
McKesson  
Meditech  
Rating Stars (Click) National Patient Safety Goals: 1 2 3 4  
Accurate patient identification  
Effective communication  
Pain assessment & management  
Infection control  
Universal precautions  
Care of patients in isolation  
Minimize risk of falls  
Prevention of pressure ulcers  
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  
Infant (birth to 1 year)  
Toddler (ages 1-3 years)  
Preschooler (ages 3-5 years)  
Childhood (ages 6-12 years)  
Adolescents (ages 12-21 years)  
Young Adults (ages 21-39 years)  
Adults (ages 40-64 years)  
Older Adults (ages 65-79 years)  
Elderly (ages 80+ years)  
Rating Stars (Click) Please list any Additional Skills:  
1  
2  
3  
4  
Additional training:  
1  
2  
3  
4  
Equipment: (i.e. Passy Muir Valve, Shiley Valve):  
1  
2  
3  
4