TELE/PCU/Stepdown Skills Checklist

TELE / PCU / Stepdown 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

Cardiac / Vascular*

	Proficiency	Frequency
12 Lead EKG Performance
Cardioversion
Carotid Endarterectomy
Dysrhythmia Interpretation and Management
Epicardial Pacing Wires
Pacemaker - Temporary / Permanent
Post Vascular Surgery
Pre / Post Cardiac Cath
Pre / Post Open Heart Surgery
Recognizing & Activating Resuscitation Event
Sheath Removal

Pulmonary*

	Proficiency	Frequency
Assist With Chest Tube Placement & Management
Chest Physiotherapy
External CPAP / BiPAP
Intubation / Extubation
Post Thoracic Surgery
Ventilator / Trach Management / Chronic / Stable Vents

Neurologic & Psychiatric*

	Proficiency	Frequency
Brain Injury
CVA
ETOH / Drug Withdrawal (CIWAL)
Glasgow Coma Scale
Post Craniotomy
Spinal Cord Injury
Stroke Scale Assessment

Endocrine / Metabolic*

	Proficiency	Frequency
Diabetes - Hypo / Hyperglycemic Crisis
Indwelling Insulin Pumps
IV Insulin Protocols / Insulin Drips
Transplants

Integumentary*

	Proficiency	Frequency
Sterile Dressing Changes
Wound Drains
Wound Staging & Care
Wound Vac

Medications*

	Proficiency	Frequency
Anti-Arrhythmic
Anticoagulants (IV, Oral, & Injection)
Anti-Hypertensives
Anti-Psychotics
Anti-Seizure Medications
Bar Coding for Medication Administration
Benzodiazepines
Chemotherapy Administration
Diuretics
Manage Vasoactive Drips - No Titration (Heparin not Included)
Narcotics / Opioid Analgesics (IV, Oral, & Injection)
Nitrates (Oral & Topical)
Non-Opioid Analgesics (IV, Oral, & Injection)
PCA Pumps
Titrate Vasoactive Drips (Heparin not Included)

IV Therapy*

	Proficiency	Frequency
Starting IVs
PICC Line Care / Blood Draws
Central Line / Implanted Line Care / Blood Draws
TPN & Lipids
Blood Product Administration
Arterial Line Management

Professional Knowledge & Skills*

	Proficiency	Frequency
Charge Experience
Fall Risk Assessment / Prevention
Infection Prevention
Interpretation and Communication of Lab Values
Isolation Precautions
National Patient Safety Goals / Core Measures
Pain Assessment & Management
Patient / Family Teaching
Pressure Ulcer Risk Assessment / Prevention
Restraints / Use of Least Restrictive Device
Specialty Beds

Gynecology General Skills*

	Proficiency	Frequency
GYN Exam Prep
Ectopic Pregnancy / Ruptures Ectopic Pregnancy
Hysterectomy
Repair of Cystocele / Rectocele

Orthopedic General Skills*

	Proficiency	Frequency
Assessment of C / M / S
K-Wises / Steinman Pins
Removal of Hardware
Total Joint Replacement
Spica Cast / Body Cast
Amputation
Traction
Ortho Trauma
Laminectomy

Endocrine General Skills*

	Proficiency	Frequency
Diabetic Teaching
Blood Glucose Monitoring
Hyper / Hypoglycemia

EMR*

	Proficiency	Frequency
Epic
Cerner
Eclipsys
McKesson
Allscripts
GE
Meditech
Computerized Physician Order Entry - CPOE
Medication Administration Using Bar Coding Technology

Age Specific Criteria*

	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 and up)

Background Experience*

	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.*

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