Medical/Surgical Skills Checklist Date:* Name: (First, MI, Last)* Email CARDIACAngina:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Acute MI:* N/A Inexperienced Limited Experience Experienced Highly Experienced Congestive Heart Failure:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Cardiac Cath:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Cardiac Surgery:* N/A Inexperienced Limited Experience Experienced Highly Experienced Aneurysm:* N/A Inexperienced Limited Experience Experienced Highly Experienced Carotid Endarterectomy:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Vascular Surgery:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Cardiac Transplant:* N/A Inexperienced Limited Experience Experienced Highly Experienced PULMONARYPneumonia:* N/A Inexperienced Limited Experience Experienced Highly Experienced COPD:* N/A Inexperienced Limited Experience Experienced Highly Experienced Tuberculosis:* N/A Inexperienced Limited Experience Experienced Highly Experienced Pulmonary Embolism:* N/A Inexperienced Limited Experience Experienced Highly Experienced Tracheostomy Management:* N/A Inexperienced Limited Experience Experienced Highly Experienced CPAP/BiPap:* N/A Inexperienced Limited Experience Experienced Highly Experienced Interpretation of Arterial Blood Gases:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Lung Transplant:* N/A Inexperienced Limited Experience Experienced Highly Experienced NEUROLOGICAL & PSYCHIATRICStroke Scale Assessment:* N/A Inexperienced Limited Experience Experienced Highly Experienced Traumatic Brain Injury:* N/A Inexperienced Limited Experience Experienced Highly Experienced CVA:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Craniotomy:* N/A Inexperienced Limited Experience Experienced Highly Experienced Seizure Disorders:* N/A Inexperienced Limited Experience Experienced Highly Experienced Spinal Cord Injuries:* N/A Inexperienced Limited Experience Experienced Highly Experienced Mood Disorders:* N/A Inexperienced Limited Experience Experienced Highly Experienced Substance Withdrawal:* N/A Inexperienced Limited Experience Experienced Highly Experienced ORTHOPEDICSCirculation/Skin Checks:* N/A Inexperienced Limited Experience Experienced Highly Experienced Continuous Passive Motion Devices:* N/A Inexperienced Limited Experience Experienced Highly Experienced Ambulation Assistive Devices:* N/A Inexperienced Limited Experience Experienced Highly Experienced Prosthetics:* N/A Inexperienced Limited Experience Experienced Highly Experienced Cast Care:* N/A Inexperienced Limited Experience Experienced Highly Experienced Pin Care:* N/A Inexperienced Limited Experience Experienced Highly Experienced Traction:* N/A Inexperienced Limited Experience Experienced Highly Experienced Total Joint Replacement :* N/A Inexperienced Limited Experience Experienced Highly Experienced Amputation:* N/A Inexperienced Limited Experience Experienced Highly Experienced GASTROINTESTINALBariatrics:* N/A Inexperienced Limited Experience Experienced Highly Experienced Feeding tubes:* N/A Inexperienced Limited Experience Experienced Highly Experienced GI Bleeding:* N/A Inexperienced Limited Experience Experienced Highly Experienced Bowel Obstruction:* N/A Inexperienced Limited Experience Experienced Highly Experienced GI Surgery:* N/A Inexperienced Limited Experience Experienced Highly Experienced Liver Disease:* N/A Inexperienced Limited Experience Experienced Highly Experienced Pancreatitis:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Liver Transplant:* N/A Inexperienced Limited Experience Experienced Highly Experienced Post Pancreas Transplant:* N/A Inexperienced Limited Experience Experienced Highly Experienced RENAL/GENITOURINARYArteriovenous Fistula/Shunt:* N/A Inexperienced Limited Experience Experienced Highly Experienced 3 Way Catheter & Bladder Irrigation:* N/A Inexperienced Limited Experience Experienced Highly Experienced Suprapubic Catheter:* N/A Inexperienced Limited Experience Experienced Highly Experienced Renal Failure:* N/A Inexperienced Limited Experience Experienced Highly Experienced Peritoneal Dialysis:* N/A Inexperienced Limited Experience Experienced Highly Experienced GU Surgery:* N/A Inexperienced Limited Experience Experienced Highly Experienced Nephrostomy Tubes:* N/A Inexperienced Limited Experience Experienced Highly Experienced Renal Transplant:* N/A Inexperienced Limited Experience Experienced Highly Experienced Management Pre/Post Hemodialysis:* N/A Inexperienced Limited Experience Experienced Highly Experienced Gyn Surgery:* N/A Inexperienced Limited Experience Experienced Highly Experienced ENDOCRINE METABOLICDiabetes Type I:* N/A Inexperienced Limited Experience Experienced Highly Experienced Diabetes Type II:* N/A Inexperienced Limited Experience Experienced Highly Experienced Blood Glucose Monitoring:* N/A Inexperienced Limited Experience Experienced Highly Experienced IV Insulin Protocols:* N/A Inexperienced Limited Experience Experienced Highly Experienced Management of Hypoglycemia:* N/A Inexperienced Limited Experience Experienced Highly Experienced Indwelling Insulin Pumps:* N/A Inexperienced Limited Experience Experienced Highly Experienced Pituitary Disorders:* N/A Inexperienced Limited Experience Experienced Highly Experienced Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledONCOLOGYChemotherapy Administration:* N/A Inexperienced Limited Experience Experienced Highly Experienced Radiation Therapy:* N/A Inexperienced Limited Experience Experienced Highly Experienced Medical Oncology:* N/A Inexperienced Limited Experience Experienced Highly Experienced Surgical Oncology:* N/A Inexperienced Limited Experience Experienced Highly Experienced Radiation Implants:* N/A Inexperienced Limited Experience Experienced Highly Experienced Bone Marrow Transplant:* N/A Inexperienced Limited Experience Experienced Highly Experienced MEDICATIONSAntiarrhythmics:* N/A Inexperienced Limited Experience Experienced Highly Experienced Anticoagulants (IV, oral, & injection):* N/A Inexperienced Limited Experience Experienced Highly Experienced Anti-Depressants:* N/A Inexperienced Limited Experience Experienced Highly Experienced Anti-Hypertensives:* N/A Inexperienced Limited Experience Experienced Highly Experienced Anti-Psychotics:* N/A Inexperienced Limited Experience Experienced Highly Experienced Benzodiazepines:* N/A Inexperienced Limited Experience Experienced Highly Experienced Emergency Medications:* N/A Inexperienced Limited Experience Experienced Highly Experienced Epidural Analgesia:* N/A Inexperienced Limited Experience Experienced Highly Experienced Inhaled Medications:* N/A Inexperienced Limited Experience Experienced Highly Experienced Insulin:* N/A Inexperienced Limited Experience Experienced Highly Experienced Narcotics/Opioid Analgesics (IV, oral, & injection):* N/A Inexperienced Limited Experience Experienced Highly Experienced Nitrates (Oral & Topical):* N/A Inexperienced Limited Experience Experienced Highly Experienced Non-Opioid Analgesics (IV, Oral, & Injection):* N/A Inexperienced Limited Experience Experienced Highly Experienced Oral Hypoglycemics:* N/A Inexperienced Limited Experience Experienced Highly Experienced Patient Controlled Analgesia:* N/A Inexperienced Limited Experience Experienced Highly Experienced Procedural Sedation Administration:* N/A Inexperienced Limited Experience Experienced Highly Experienced Reversal Agents:* N/A Inexperienced Limited Experience Experienced Highly Experienced Steroids (IV, Oral, Inhaled):* N/A Inexperienced Limited Experience Experienced Highly Experienced Automated Medication Dispensing Systems (i.e. Pyxis, Omnicell):* N/A Inexperienced Limited Experience Experienced Highly Experienced IV THERAPYStarting IVs:* N/A Inexperienced Limited Experience Experienced Highly Experienced Central Line Blood Draws:* N/A Inexperienced Limited Experience Experienced Highly Experienced Central Line/Implanted Line Care:* N/A Inexperienced Limited Experience Experienced Highly Experienced TPN & Lipids:* N/A Inexperienced Limited Experience Experienced Highly Experienced Blood Product Administration:* N/A Inexperienced Limited Experience Experienced Highly Experienced Monitoring of Chemotherapy:* N/A Inexperienced Limited Experience Experienced Highly Experienced CARDIAC MONITORING & EMERG. RESPONSEPlacement of Telemetry Leads:* N/A Inexperienced Limited Experience Experienced Highly Experienced Rhythm Interpretation:* N/A Inexperienced Limited Experience Experienced Highly Experienced Dysrhythmia Management:* N/A Inexperienced Limited Experience Experienced Highly Experienced Obtain 12 Lead EKG:* N/A Inexperienced Limited Experience Experienced Highly Experienced Use of Rapid Response Teams:* N/A Inexperienced Limited Experience Experienced Highly Experienced PROFESSIONAL KNOWLEDGE AND SKILLSNational Patient Safety Goals/Core Measures:* N/A Inexperienced Limited Experience Experienced Highly Experienced Fall Risk Assessment/Prevention:* N/A Inexperienced Limited Experience Experienced Highly Experienced Pressure Ulcer Risk Assessment/Prevention:* N/A Inexperienced Limited Experience Experienced Highly Experienced Restraints/Use of Least Restrictive Device:* N/A Inexperienced Limited Experience Experienced Highly Experienced Patient/Family Teaching:* N/A Inexperienced Limited Experience Experienced Highly Experienced Age Specific/Population-Based Care:* N/A Inexperienced Limited Experience Experienced Highly Experienced Isolation Precautions:* N/A Inexperienced Limited Experience Experienced Highly Experienced Infection Prevention:* N/A Inexperienced Limited Experience Experienced Highly Experienced Pain Assessment & Management:* N/A Inexperienced Limited Experience Experienced Highly Experienced Charge Experience:* N/A Inexperienced Limited Experience Experienced Highly Experienced Interpretation and Communication of Lab Values:* N/A Inexperienced Limited Experience Experienced Highly Experienced Wound Care /Wound Vac:* N/A Inexperienced Limited Experience Experienced Highly Experienced Specialty Beds:* N/A Inexperienced Limited Experience Experienced Highly Experienced EMREpic:* N/A Inexperienced Limited Experience Experienced Highly Experienced Cerner:* N/A Inexperienced Limited Experience Experienced Highly Experienced Eclipsys:* N/A Inexperienced Limited Experience Experienced Highly Experienced McKesson:* N/A Inexperienced Limited Experience Experienced Highly Experienced Meditech:* N/A Inexperienced Limited Experience Experienced Highly Experienced Other Computerized System:* N/A Inexperienced Limited Experience Experienced Highly Experienced Computerized Physician Order Entry:* N/A Inexperienced Limited Experience Experienced Highly Experienced EMR conversion* No Yes CERTIFICATIONSBLS MM slash DD slash YYYY ACLS MM slash DD slash YYYY Telemetry Certificate MM slash DD slash YYYY ONS Chemo/Biotherapy Certification MM slash DD slash YYYY Other Chemo Certification MM slash DD slash YYYY Areas of Expertise:Consent* By submitting this form, I agree to all terms and conditions and agree to authorize consent NameThis field is for validation purposes and should be left unchanged.