Medical/Surgical Skills Checklist

Medical / Surgical Skills Checklist

First Name*

Last Name*

Years of Experience*

E-mail*

example@example.com

ANSWER KEY

PROFICIENCY

1=Not Applicable 2=No Experience 3=Some Experience

4=Experienced 5=Very Experienced

FREQUENCY

1=Never Performed 2=Assisted Only 3=Rarely Performed

4=Occasionally Performed 5=Regularly Performed

General Skills*

Rows	Proficiency	Frequency
Standard Precautions
Isolation Precautions
Pediatric Respiratory / Cardiac Arrest
Adult Respiratory / Cardiac Arrest
Crash Carts
Defibrillators
Care of Patients in Restraints
Pain Management
Automated Med Dispensing Systems
Care Planning & Discharge Planning
Patient / Family Education
Electronic Documentation
Patient Head to Toe Assessment

Medications*

Rows	Proficiency	Frequency
Narcotics
PCA for Pain Control
Epidural for Pain Control
Non-Carcotic Analgesics
Topical Medications
SQ Medications
Oral Medications
IV Push Medications
IV Drip Medications
Antibiotics
Chemotherapy

General Skills*

Rows	Proficiency	Frequency
Assessing Levels of Consciousness
Pupil Checks
Seizure Precautions
Aneurysm Precautions
Assisting With Lumbar Puncture
Use of Hyper / Hypothermia Blanket

Care of Patients With*

Rows	Proficiency	Frequency
Spinal Cord Injury - Acute
Spinal Cord Injury – Long Term
Neuromuscular Disease
Alzheimer Disease

Knowledge and Use of*

Rows	Proficiency	Frequency
Anticonvulsants
IV Drip Steroids

General Skills*

Rows	Proficiency	Frequency
Cardiac Monitors
EKG- 12 Lead
Recognizing Basic & Life-Threatening Dysrhythmias
Cardioversion
Pulse Checks
Use of Doppler
Use of Automatic BP Cuff (i.e. Dinamap)

Care of Patients With*

Rows	Proficiency	Frequency
CHF
Chest Pain
Post MI

Knowledge and Use of*

Rows	Proficiency	Frequency
Nitrates (Oral, Topical)
Antiarrhythmics (Oral)
Antihypertensives (Oral)
Heparin Drip

General Skills*

Rows	Proficiency	Frequency
O2 Cannulas / Masks
Nebulizer Set-up / Use
Incentive Spirometry
Chest PT
Pulse Oximetry
Suctioning
Oral
Tracheostomy Tube

Care of Patients With*

Rows	Proficiency	Frequency
Tracheostomy Tube
COPD
Asthma Exacerbation
Pneumonia
Pre / Post Thoracic Surgery
Chest Tubes
Tuberculosis

Knowledge and Use of*

Rows	Proficiency	Frequency
Bronchodilators
Oral
IV
Inhaler

General Skills*

Rows	Proficiency	Frequency
Insertion, Care & Maintenance of Nasogastric Tubes (i.e. Salem Pump, Levine)
Nasointestinal Tubes (i.e. Cantor, Miller-Abbot)
Jejunostomy, Gastrostomy, Cecostomy Tubes

Tube Feedings Via Flexible Tubes*

Rows	Proficiency	Frequency
By Gravity Infusion
By Feeding Pump
Collection of Stool Specimens
Bowel Preparation & Cleansing Procedures

Care of Patients With*

Rows	Proficiency	Frequency
Post Abdominal Surgery
Ileostomy
Colostomy
Inflammatory Bowel Disease
Obstruction
Hepatitis

Medication Knowledge and Use of*

Rows	Proficiency	Frequency
Total Parenteral Nutrition (TPN)
Peripheral Parenteral Nutrition (PPN) Antiemetics
Proton Pump Inhibitors

General Skills*

Rows	Proficiency	Frequency
Insertion of Catheter (Straight & Foley)
Bladder Irrigation Continuous
Bladder Irrigation Intermittent

Peritoneal Dialysis*

Rows	Proficiency	Frequency
Manual
Automatic Cycler Machine
Collection of Urine Specimens
Hemodialysis
A-V Fistula / Shunt Care
Pre- & Post- Dialysis Care
Suprapubic Catheter
Nephrostomy Tube

Care of Patients With*

Rows	Proficiency	Frequency
Urinary Tract Infection
Pyelonephritis
Renal Calculi
Urinary Retention / Incontinence

General Skills*

Rows	Proficiency	Frequency
Performing Fingersticks
Use of Blood Glucose Meter Device
Use of Visual Blood Glucose Strips

Care of Patient With*

Rows	Proficiency	Frequency
Hyper / Hypoglycemia

Knowledge and Use of Insulin*

Rows	Proficiency	Frequency
Single Type
Mixed Insulins
Insulin Infusion

General Skills*

Rows	Proficiency	Frequency
Cast Care
C.M.S. Checks
Traction – Skin
Traction – Skeletal
Range of Motion
Use of Assistive Devices
Applications of Splints of Extremities
Continuous Passive Motion Machine (CPM)

Care of Patients With*

Rows	Proficiency	Frequency
Total Joint Replacement
Rheumatic / Arthritic Disease
Amputation

General Skills*

Rows	Proficiency	Frequency
Dressing Changes
Use of Special Pressure Relief Devices
Air Fluidized, Low Air Loss Beds
Pressure Relief Mattress / Seat Cushion

Care of Patient With*

Rows	Proficiency	Frequency
Pressure Sores
Leg Ulcers
Burns

Care of Patient With*

Rows	Proficiency	Frequency
Hemovacs
Jackson-Pratt Tubes
Penrose Drains
T-Tubes
Surgical Wound Irrigations & Dressings
Oncology

Vascular Draw Blood*

Rows	Proficiency	Frequency
Arterial Line
Central Line
Peripheral IV Insertion, Care & Maintenance
Discontinue Peripheral IV
IV Infusion Pumps
CVP Lines – Measurement of CVP
Central Line Care & Maintenance (Including Dressing Changes)
Blood/Blood Product Administration
Multi-Lumen Central Catheters
Port-A-Cath (Infusa-Ports)
Continuous Subcutaneous Infusion Pumps

Age Specific Criteria*

Rows	Proficiency	Frequency
Newborn / Neonatal (up to 30 days)
Infant (30 days to 1 year)
Toddler (1 to 3 years)
Preschooler (3 to 5 years)
School Age (5 to 12 years)
Adolescents (12 to 18 years)
Young Adults (18 to 39 years)
Middle Adults (40 to 64 years)
Older Adults (65 & up)

Background Experience*

Rows	Proficiency	Frequency
Small Hospital
Large Hospital
Outpatient
Acute Care / Hospital
Cancer Center
Clinic
Managed Care
SNF / Long Term Care
Home Health

The information provided is true and to the best of my knowledge. I hereby authorize Summit Medical Staffing to present my Skills Checklist to facilities for the purpose of employment. Please Type Your Name in This Box to Electronically Sign this Form.*

First NameLast Name

Date*

MonthDayYear

Hour MinutesAM/PM Option

Form Reply Email Address

Neurologic

Cardiac

Respiratory

Gastrointestinal

Genitourinary / Renal

Endocrine

Orthopedic

Wound / Skin Problem

Additional Medical / Surgical Skills