Age of Patients Cared ForNewborn/Neonate (Birth to 30 days)* 1 2 3 4 Infant (31 days to 12 months)* 1 2 3 4 Toddler/Preschool (13 months to 5 years)* 1 2 3 4 School Age Child/Adolescent (6 years to 18 years)* 1 2 3 4 Young Adults/Middle Adult (19 years to 64 years)* 1 2 3 4 Older Adults/Elderly (65+ years)* 1 2 3 4 Type of Facility ExperienceList facility types:*General SkillsStandard Precautions* 1 2 3 4 Isolation Precautions* 1 2 3 4 Pain Management* 1 2 3 4 Care of Patient in Restraints* 1 2 3 4 Automated Med Dispensing Systems* 1 2 3 4 List Types:*Peripheral IV Insertion, Care and Maintenance* 1 2 3 4 Access/Management of Implanted Ports* 1 2 3 4 Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, Etc.)* 1 2 3 4 Patient/Family Education* 1 2 3 4 Knowledge of "Do not use abbreviations"* 1 2 3 4 Charge/Supervisor Experience* 1 2 3 4 Knowledge of Current Joint Commission National Patient Safety Goals* 1 2 3 4 Knowledge/Familiarity with HCAHPS Scores* 1 2 3 4 MedicationsKnowledge and Use of:Pouring from Stock Medications* 1 2 3 4 Narcotic Administration* 1 2 3 4 IV Push/Drip Medications* 1 2 3 4 Antibiotics* 1 2 3 4 Oral* 1 2 3 4 Topical* 1 2 3 4 Otic* 1 2 3 4 Rectal* 1 2 3 4 Vaginal* 1 2 3 4 Ophthalmic* 1 2 3 4 Continuous Subcutaneous Infusion Pumps* 1 2 3 4 Peripheral Parenteral Nutrition* 1 2 3 4 Patient Controlled Analgesia (PCA)* 1 2 3 4 Phlebotomy / IV TherapyBlood Draw-Peripheral* 1 2 3 4 Mixing IVs* 1 2 3 4 Regulating IVs* 1 2 3 4 IV Infusion Pumps* 1 2 3 4 Blood/Blood Product Administration* 1 2 3 4 IV Pumps* 1 2 3 4 List Types:*Cardiac GeneralRecognizing Basic & Life-Threatening Dysrhythmias* 1 2 3 4 Congestive Heart Failure* 1 2 3 4 Cardiac-Care of Patient with:Pulse Checks* 1 2 3 4 Cardiac Monitors* 1 2 3 4 Obtaining EKGs - 12 Lead* 1 2 3 4 Use Of Automatic Bp Cuff (ie Dinamap)* 1 2 3 4 Knowledge and Use of:Nitrates (Oral, Topical)* 1 2 3 4 Antiarrythmics (Oral)* 1 2 3 4 Antihypertensives (Oral)* 1 2 3 4 Respiratory GeneralEmphysema* 1 2 3 4 COPD* 1 2 3 4 Asthma Exacerbation* 1 2 3 4 Tracheostomy* 1 2 3 4 Pneumonia* 1 2 3 4 Pre/Post Thoracic Surgery* 1 2 3 4 Chest Tubes* 1 2 3 4 RespiratoryCare of Patient with:Collection of Sputum Specimen* 1 2 3 4 O2 Cannulas/Masks* 1 2 3 4 Non-Rebreather Mask* 1 2 3 4 Nebulizer Set-Up/Use* 1 2 3 4 Incentive Spirometry* 1 2 3 4 Chest PT* 1 2 3 4 Suctioning (Oral/Nasotracheal)* 1 2 3 4 Suctioning (Tracheostomy Tube)* 1 2 3 4 Ventilator Patient (Mouth Care, Suctioning, Ambu Bag)* 1 2 3 4 Knowledge and Use of:Bronchodilators (Oral, IV, Inhaler)* 1 2 3 4 Steroids* 1 2 3 4 Neuro GeneralSpinal Cord Injury - Acute* 1 2 3 4 Spinal Cord Injury - Long Term* 1 2 3 4 CVA Stroke* 1 2 3 4 Neuromuscular Disease* 1 2 3 4 Alzheimer Disease* 1 2 3 4 Wandering* 1 2 3 4 Hallucinations* 1 2 3 4 Anxiousness* 1 2 3 4 Agitation* 1 2 3 4 Reality Orientation* 1 2 3 4 Neuro-Care of Patient with:Assessing Levels of Consciousness* 1 2 3 4 Pupil Checks* 1 2 3 4 Seizure Precautions* 1 2 3 4 Stroke Precautions* 1 2 3 4 Swallow Precautions* 1 2 3 4 Assisting With Lumbar Puncture* 1 2 3 4 Use of Hyper/Hypothermia Blanket* 1 2 3 4 Sensory DeficitsCare of Patient with: Dentures* 1 2 3 4 Hearing Aid Devices* 1 2 3 4 Care of Patients with Hearing Loss* 1 2 3 4 Prosthetic Eye* 1 2 3 4 Contact Lens Care* 1 2 3 4 Cataracts* 1 2 3 4 Blindness* 1 2 3 4 Macular Degeneration* 1 2 3 4 Knowledge and Use of:Anticonvulsant* 1 2 3 4 Sedative* 1 2 3 4 GI GeneralNasogastric Tubes (I.E. Salem Sump, Levine)* 1 2 3 4 Nasointestinal Tubes (I.E. Cantor, Miller-Abbot)* 1 2 3 4 Jejunostomy, Gastrostomy, Cecostomy Tubes* 1 2 3 4 Colostomy, Ileostomy* 1 2 3 4 Administration of Tube Feedings Via Flexible Tubes* 1 2 3 4 By Gravity Infusion* 1 2 3 4 By Feeding Pump* 1 2 3 4 GastrointestinalCare of Patient with:Collection of Stool Specimens* 1 2 3 4 Bowel Preparation and Cleansing Procedures* 1 2 3 4 Bowel Disimpaction* 1 2 3 4 Bowel Retraining* 1 2 3 4 Sitz Bath Treatments* 1 2 3 4 Inserting and Checking Placement/Patency NG Tubes* 1 2 3 4 Endocrine GeneralDiabetes* 1 2 3 4 Hyper/Hypoglycemia* 1 2 3 4 EndocrineCare of Patient with:Blood Glucose Monitoring* 1 2 3 4 Performing Fingersticks* 1 2 3 4 Use of Blood Glucose Meter Device* 1 2 3 4 Use of Visual Blood Glucose Strips* 1 2 3 4 Knowledge and Use of:Insulin* 1 2 3 4 Single Type* 1 2 3 4 Mixed Insulins* 1 2 3 4 Insulin Infusion* 1 2 3 4 Renal/GU GeneralIncontinence* 1 2 3 4 Urinary Retention* 1 2 3 4 UTI* 1 2 3 4 Renal/GUCare of Patient with:Insertion of Catheter - Female* 1 2 3 4 Insertion of Catheter - Male* 1 2 3 4 Insertion of Suprapubic Catheter* 1 2 3 4 Applications of Condom Catheter* 1 2 3 4 Bladder Retraining* 1 2 3 4 Urinary Diversion* 1 2 3 4 Bladder Irrigation (Continuous and Intermittent)* 1 2 3 4 Peritoneal Dialysis* 1 2 3 4 Manual* 1 2 3 4 Automatic Cycler Machine* 1 2 3 4 Orthopedic GeneralTotal Joint Replacement* 1 2 3 4 Rheumatic/Arthritic Disease* 1 2 3 4 Amputation* 1 2 3 4 Fracture* 1 2 3 4 OrthopedicCare of Patient with:Cast Care* 1 2 3 4 CMS Checks* 1 2 3 4 Traction - Skin* 1 2 3 4 Traction - Skeletal* 1 2 3 4 Range of Motion* 1 2 3 4 Use of Assistive Devices* 1 2 3 4 Applications of Splints of Extremities* 1 2 3 4 Continuous Passive Motion Machine (CPM)* 1 2 3 4 Transfer Techniques* 1 2 3 4 Use of a Sliding Board* 1 2 3 4 Gait Training/Retraining* 1 2 3 4 Application of Prosthetic Devices* 1 2 3 4 Application of Orthotic Devices* 1 2 3 4 Wound/SkinCare of Patient with:Pressure Sores* 1 2 3 4 Leg Ulcers* 1 2 3 4 Burns* 1 2 3 4 Wound/Skin GeneralAcute Dressing Changes* 1 2 3 4 Wound Care* 1 2 3 4 Irrigations* 1 2 3 4 Identifying Common Skin Problems* 1 2 3 4 Recognizing Normal Skin Changes* 1 2 3 4 Use of Special Pressure Relief Devices* 1 2 3 4 Pressure Relief Mattress/Seat Cushion* 1 2 3 4 Additional SkillsCare of Patient with:Hemovacs* 1 2 3 4 Jackson-Pratt Tubes* 1 2 3 4 Enrose Drains* 1 2 3 4 Please list the EMR systems you have used** I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form.** I hereby consent to allow CrossMed Healthcare Staffing Solutions to release these skills checklist to the client facilities.*Name* First Last Email* Phone*TODAY'S DATE* MM slash DD slash YYYY
