Age of Patients Cared ForNewborn/Neonate (birth to 30 days)* 1 2 3 4 Infant (1 month to 1 year)* 1 2 3 4 Toddler (1 year to 3 years)* 1 2 3 4 Preschooler (3 years to 5 years)* 1 2 3 4 School Age Child (5 years to 12 years)* 1 2 3 4 Adolescents (12 years to 18 years)* 1 2 3 4 Young Adults (18 years to 39 years)* 1 2 3 4 Middle Adults (39 years to 64 years)* 1 2 3 4 Older Adults (64 years to 79 years)* 1 2 3 4 General SkillsPatient and Family Teaching* 1 2 3 4 Coaching Needs* 1 2 3 4 Universal Precautions* 1 2 3 4 Isolation Precautions* 1 2 3 4 Care of Patient in Restraints* 1 2 3 4 Cardiac Monitoring* 1 2 3 4 Pulse Oximetry* 1 2 3 4 Ventilator Management (Adult)* 1 2 3 4 Ventilator Management (Newborn)* 1 2 3 4 Prep and Administration of Emergency Meds* 1 2 3 4 Infant/Neonatal Cardiac/Respiratory Distress* 1 2 3 4 Adult Cardiac/Respiratory Distress* 1 2 3 4 End of Life Care* 1 2 3 4 Fetal Monitoring – Basic* 1 2 3 4 Fetal Monitoring – Advanced* 1 2 3 4 IV Therapy* 1 2 3 4 Administration of Blood and Blood Products* 1 2 3 4 Knowledge of Normal Lab Levels* 1 2 3 4 Newborn* 1 2 3 4 Labor Patient* 1 2 3 4 Pain Management* 1 2 3 4 Automated Med Dispensing System* 1 2 3 4 List Types:*Care of Patients with Pre-Existing Conditions/High Risk OBCardiac Disease* 1 2 3 4 Neurological Disease* 1 2 3 4 Seizure Disorder* 1 2 3 4 Chronic Diabetes Mellitus* 1 2 3 4 Pregnancy Induced Diabetes* 1 2 3 4 Asthma* 1 2 3 4 Chronic Hypertension* 1 2 3 4 Pregnancy-Induced Hypertension* 1 2 3 4 Infectious Disease* 1 2 3 4 HBV* 1 2 3 4 HIV* 1 2 3 4 Sickle Cell Disease* 1 2 3 4 RH Incompatibilities* 1 2 3 4 Hemolytic Anemia* 1 2 3 4 Collagen Vascular Disease* 1 2 3 4 Hemorrhage* 1 2 3 4 Drug Addiction/Withdrawal* 1 2 3 4 Pyelonephritis* 1 2 3 4 Abruptio Placenta* 1 2 3 4 Placenta Previa* 1 2 3 4 Placenta Acreta* 1 2 3 4 Preeclampsia* 1 2 3 4 Eclampsia* 1 2 3 4 Premature Labor* 1 2 3 4 Malpresentations* 1 2 3 4 Breech* 1 2 3 4 Transverse Lie/Shoulder* 1 2 3 4 Face Presentation* 1 2 3 4 Brow Presentation* 1 2 3 4 Multiple Gestation* 1 2 3 4 PROM* 1 2 3 4 Chorioamnionitis* 1 2 3 4 Poly/Oligohydramnios* 1 2 3 4 Prior Tubal Ligation* 1 2 3 4 VBAC Management/Trial of Labor* 1 2 3 4 Uterine Rupture* 1 2 3 4 Incompetent Cervix (Shirodkar Suture/Cerclage)* 1 2 3 4 Spontaneous Abortions-Complete/Incomplete* 1 2 3 4 Intrauterine Growth Retardation (IUGR)* 1 2 3 4 Postdate Pregnancy* 1 2 3 4 HELLP Syndrome* 1 2 3 4 DIC* 1 2 3 4 Fetal Demise* 1 2 3 4 AntepartumTriage of Obstetrical Patients* 1 2 3 4 Assessment of Birth Plan* 1 2 3 4 Perform Admission Risk Assessment* 1 2 3 4 Non-Stress Test (NST)* 1 2 3 4 Induction of Labor* 1 2 3 4 Oxytocin Challenge Tests (OCT)* 1 2 3 4 Biophysical Profile* 1 2 3 4 Assist with Sonogram* 1 2 3 4 Perform Sonogram* 1 2 3 4 Assist with Amniocentesis* 1 2 3 4 Normal Perinatal Vital Signs* 1 2 3 4 Deep Tendon Reflex Checks* 1 2 3 4 Edema Assessment* 1 2 3 4 Clonus* 1 2 3 4 Assess for Comfort* 1 2 3 4 Breathing/Relaxation Techniques* 1 2 3 4 Coaching* 1 2 3 4 Positioning* 1 2 3 4 MedicationsRitodrine* 1 2 3 4 Magnesium Sulfate* 1 2 3 4 Terbutaline* 1 2 3 4 Indomethacin* 1 2 3 4 Procardia* 1 2 3 4 Pitocin* 1 2 3 4 Oxytocin* 1 2 3 4 Cervidil* 1 2 3 4 Cytotec* 1 2 3 4 Prostin Suppositories* 1 2 3 4 Assist with Prostin Gel* 1 2 3 4 Antibiotics* 1 2 3 4 Antihypertensives* 1 2 3 4 Heparin* 1 2 3 4 Stadol* 1 2 3 4 Nubain* 1 2 3 4 Morphine* 1 2 3 4 Demerol* 1 2 3 4 Fentanyl* 1 2 3 4 Insulin Drips* 1 2 3 4 Insulin Pumps* 1 2 3 4 Insulin SC* 1 2 3 4 AZT/Other Antiviral Medications* 1 2 3 4 Rhogam* 1 2 3 4 IV Therapy/ProceduresStarting IV’s* 1 2 3 4 PICC Lines-Care and Maintenance* 1 2 3 4 Central Venous Lines – Care and Maintenance* 1 2 3 4 Invasive Hemodynamic Monitoring* 1 2 3 4 Blood Draw from PICC/CVL* 1 2 3 4 Administration of Blood Products* 1 2 3 4 IV Infusion Pumps* 1 2 3 4 Blood/Fluid Warmers* 1 2 3 4 Labor Assessment/Procedures: MaternalNormal Vital Signs – Baseline* 1 2 3 4 Identify Common Cardiac Arrhythmia* 1 2 3 4 Assist with Sterile Speculum Exam* 1 2 3 4 Perform Sterile Speculum Exam* 1 2 3 4 Vaginal Exam – Manual* 1 2 3 4 Status of Membranes* 1 2 3 4 Assist with Rupture of Membranes* 1 2 3 4 Fern Test* 1 2 3 4 Nitrazine* 1 2 3 4 Presence of Clonus* 1 2 3 4 DTR’s* 1 2 3 4 Edema* 1 2 3 4 Progression of Labor* 1 2 3 4 Dilation* 1 2 3 4 Effacement* 1 2 3 4 Fetal Position* 1 2 3 4 Fetal Presentation* 1 2 3 4 Station* 1 2 3 4 Contraction Characteristics* 1 2 3 4 Determination of Fetal Head Position* 1 2 3 4 Documentation of Labor Status and Interventions* 1 2 3 4 Labor Suppressants* 1 2 3 4 Collection of Blood Specimens* 1 2 3 4 Collect Urine Specimens* 1 2 3 4 Toxicology Studies* 1 2 3 4 Collect Vaginal Cultures* 1 2 3 4 Fluid* 1 2 3 4 Herpes* 1 2 3 4 Chlamydia* 1 2 3 4 Group B Strep* 1 2 3 4 Perform Leopold’s Maneuvers* 1 2 3 4 AmnioinfusionVariable Decelerations* 1 2 3 4 Meconium* 1 2 3 4 Prolapsed Cord* 1 2 3 4 Vasa Previa* 1 2 3 4 Catheter InsertionStraight Cath* 1 2 3 4 Foley* 1 2 3 4 Labor Assessment/Procedures: FetalFetal Heart Rate – Doppler* 1 2 3 4 Fetal Heart Rate – Auscultate* 1 2 3 4 Document Fetal Position* 1 2 3 4 Fetal Heart Rate Patterns: Identify and Treat BaselineVariability* 1 2 3 4 Variable Decelerations* 1 2 3 4 Early Decelerations* 1 2 3 4 Late Decelerations* 1 2 3 4 Prolonged Decelerations* 1 2 3 4 External Fetal Monitor Application* 1 2 3 4 Internal Fetal Monitor Application (assist)* 1 2 3 4 Internal Fetal Monitor Application (Preform)* 1 2 3 4 Spiral Electrode* 1 2 3 4 Intrauterine Pressure Catheter (IUPC)Placement* 1 2 3 4 Calibration* 1 2 3 4 Fluid Filled* 1 2 3 4 Transducer Tipped* 1 2 3 4 Delivery/C-SectionAssist with Vaginal Delivery* 1 2 3 4 Forceps Extraction* 1 2 3 4 Vacuum Extraction* 1 2 3 4 Assist with High Risk Delivery* 1 2 3 4 Shoulder Dystocia* 1 2 3 4 Hemorrhage/Shock* 1 2 3 4 Emergency Delivery* 1 2 3 4 Abdominal Shave/Scrub Prep* 1 2 3 4 Perineal Prep* 1 2 3 4 Circulate C-Section* 1 2 3 4 Scrub C-Section* 1 2 3 4 Patient with General Anesthesia* 1 2 3 4 Patient with Epidural Anesthesia* 1 2 3 4 Circulate Tubal Ligation* 1 2 3 4 Scrub Tubal Ligation* 1 2 3 4 Assist with Placenta Delivery* 1 2 3 4 Fundus Massage* 1 2 3 4 Assist with Cervical Laceration Repair* 1 2 3 4 Assist with Uterine Laceration Repair* 1 2 3 4 Assist with Episiotomy Repair* 1 2 3 4 Immediate Care of Newborn in Delivery Room Newborn AssessmentBallard* 1 2 3 4 Dubowitz* 1 2 3 4 Finnegan/Abstinence Scoring* 1 2 3 4 Apgar Scores* 1 2 3 4 Initial Vital Signs* 1 2 3 4 Bulb Suctioning* 1 2 3 4 Delee Suctioning* 1 2 3 4 Wall Suctioning* 1 2 3 4 Meconium Aspiration* 1 2 3 4 Collect Cord Samples* 1 2 3 4 Assist with UAC/UVC Insertion* 1 2 3 4 Insertion of IV, Including Scalp IV* 1 2 3 4 Radiant Warmer/Thermoregulation* 1 2 3 4 Interventions of LGA, SGA, IUGR* 1 2 3 4 Intervention of Infant of Diabetic Mother* 1 2 3 4 Oxygen Administration* 1 2 3 4 Bag/Mask Ventilation of the Newborn* 1 2 3 4 Assist with Intubation* 1 2 3 4 Transport Isolette* 1 2 3 4 Heelstick* 1 2 3 4 Eye Prophylaxis* 1 2 3 4 Vitamin K* 1 2 3 4 ID/Security Banding* 1 2 3 4 Promote Bonding Behaviors* 1 2 3 4 Lead Placement for Cardiac Monitoring* 1 2 3 4 Apnea Monitoring* 1 2 3 4 Oxyhood* 1 2 3 4 Postpartum CareFundal Height* 1 2 3 4 Fundal Massage* 1 2 3 4 Lochia* 1 2 3 4 Episiotomy Care* 1 2 3 4 Perineum Care* 1 2 3 4 Maternal Vital Signs* 1 2 3 4 Recovering Post-Op C-Sections Patients* 1 2 3 4 Recovering Post-Op Tubal Litigation Patient* 1 2 3 4 Fluid Balance* 1 2 3 4 Assessment for DVT* 1 2 3 4 Couplet Care* 1 2 3 4 Breast Care* 1 2 3 4 Breastfeeding* 1 2 3 4 Newborn Care:Cord Care* 1 2 3 4 Circumcision Care* 1 2 3 4 Bath Demonstration* 1 2 3 4 Assist with Lumbar Puncture* 1 2 3 4 Administration of IV Antibiotics* 1 2 3 4 Newborn Vital Signs* 1 2 3 4 Assist with BreastfeedingLatch On* 1 2 3 4 Positioning* 1 2 3 4 Care of Infant with:Cardiac Anomalies* 1 2 3 4 Drug Addiction/Withdrawal* 1 2 3 4 Cystic Fibrosis* 1 2 3 4 Meconium Aspiration* 1 2 3 4 Pneumonia* 1 2 3 4 Pulmonary Edema* 1 2 3 4 RDS* 1 2 3 4 NEC* 1 2 3 4 Neuromuscular Disease* 1 2 3 4 Spina Bifida* 1 2 3 4 Seizure Activity* 1 2 3 4 Tracheoesophageal Fistula* 1 2 3 4 Sepsis* 1 2 3 4 Sickle Cell Disease* 1 2 3 4 Low Birth Weight Infants* 1 2 3 4 Pain ManagementAssess Pain Level* 1 2 3 4 Assess Acceptable Level of Pain* 1 2 3 4 Intranasal Pain Medication* 1 2 3 4 Oral Pain Medications* 1 2 3 4 IV Pain Medication* 1 2 3 4 PCA* 1 2 3 4 IV Conscious Sedation* 1 2 3 4 Epidural Pain Management* 1 2 3 4 Intervention for Anesthesia Toxicity* 1 2 3 4 Assist with Epidural InsertionPositioning of Patient* 1 2 3 4 Signs of Dural Puncture* 1 2 3 4 Fluid Challenge* 1 2 3 4 Hypotension* 1 2 3 4 Intrathecal Narcotics* 1 2 3 4 Experience/SettingLDR* 1 2 3 4 LDPR* 1 2 3 4 Post-Partum/Mother Baby* 1 2 3 4 Antepartum* 1 2 3 4 Rural Hospital* 1 2 3 4 Community Hospital* 1 2 3 4 0-50 Births per Month* 1 2 3 4 50-100 Births per Month* 1 2 3 4 100-200 Births per Month* 1 2 3 4 200-300 Births per Month* 1 2 3 4 300+ Birth per Month* 1 2 3 4 Please list the EMR systems you have used*Additional Skills:Additional Training:* 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
