Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Which license do you currently work under?:
*
Registered Nurse
Licensed Practical Nurse
RN/LPN SKILLS ASSESSMENT
Complete the following questions about your experience as a practicing Nurse.
Certifications (must submit copy of any certification)
*
BLS/CPR
ACLS
PALS
NRP
CPI
Experience (list departments)
*
Electronic Medical Record Experience (select all that apply)
*
None, ONLY experience with Paper Charts
Cerner
Epic
McKesson
Electronic Medication Dispensing (eMAR)
*
Yes, I have experience with eMAR
No, I have only used paper MAR
Skills List (check all that apply)
*
MedSurg
Psychiatric
PICU/NICU
Operating Room
Recovery Room
Pediatric
Oncology
Ortho/Neuro
Emergency Dept
Rehab
ICU
L&D
OB
Option 12
Cardiac/Tele
Dialysis
Trach Care
Vent Pt
Ostomy Care
Wound care
Decubiti Care
Foley Care
Telemetry Interpretation
Central Line Care
Mediport Care
Chest Tube Care
Use of Walker/Wheelchair
Interpret Lab Values
Option 28
Blood Admin
TPN admin
CBGs
Gait Training
Pt Assessment
Chemo Admin
Neuro Check
ROM
Venipuncture
Oxygen Care
Age Specific Experience Checklist
Please select "YES" or "NO" if you have experience with any of the following age related groups. Including but not limited to: Knowledge of human growth/development, ability to assess age specific date, possess skills/knowledge to perform treatments, ability yo interpret age specific response to treatments, ability to involve family and/or significant other in decision-making related to plan of care.
Neo-Natal Experience
*
YES
NO
Pediatric Experience
*
YES
NO
Adolescent Experience
*
YES
NO
Adult Experience
*
YES
NO
Geriatric Experience
*
YES
NO
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CLINICAL SKILLS SELF EVALUATION
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Med Surg Experience?
*
YES
NO
Please select the answer that most accurately describes your proficiency level. Never ; Familiar ; Experienced ; Expert
Patient Care
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
PCA pump
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Colostomy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Ileostomy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Aneurysms
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Isolation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Femoral-Popliteal Bypass
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Thoracic Surgery
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Carotid Endarterectomy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
CVA
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Spinal Cord Injury
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Craniotomy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
DT's
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Overdose
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Burns
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
GI bleeds
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
HIV / AIDS
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
ARDS
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Near Drowning
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Cardiovascular
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Heart Sounds
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Blood Pressure interpret
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
12-Lead EKG
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Telemetry Interpret
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Telemetry Lead Placement
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Doppler use
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Heart murmur
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Pulse checks
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
PaceMaker
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Assessments
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Cardiovascular Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Respiratory Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
GI Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
GU Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Nutritional Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Mental Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Musculoskeletal Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Neuro Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Integumentary Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Pain Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Psychosocial Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Wound Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Lab value Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Vital Signs Assessment
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Medication Effects / Side Effects
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Drug Interatctions
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Endocrine
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Insulin preperation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Insulin admin
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Insulin site rotation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
S/S of hypo/hyper-glycemia
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Urine Testing
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Blood testing
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Skin/Foot care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Excercise/activity/rest
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Sick day routine
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Addison's Disease
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Pituitary Disorders
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Graves Disease
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Hypo/Hyper-thyroidism
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Thyroidectomy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Pulmonary
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Apnea Monitoring
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Oralpharyngeal Suction
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Nasotracheal Suction
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Tracheostomy Care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Trach Suction
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Airway Management
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Sputum collection
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Chest Physiotherapy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Incentive Spirometry
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Oxygen Therapy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Pulse Oximetry
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Ventilator care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Chest Tube Care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Inhaler use
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Pulmonaide use
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Postural Drainage/Percussion
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Assist with ET intubation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Breathing Exercises
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
GastroIntestinal
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
NG insertion/removal/care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
NG suction
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
T-Tube
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Gastrostomy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Jejunostomy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Irrigation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Admin of Tube Feeding
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Salem Sump Suction
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Manuel Disimpaction
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Digital Rectal Exam
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
JP Drain
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Hemovac
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Renal / Genitalurinary
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Foley Insertion
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Foley Removal
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Foley Irrigation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
3-way foley cath
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Suprabuic Cath
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Nephrostomy Tube Irrigation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Peritoneal Dialysis
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Condom Cath
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Bladder Training
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Specimin Collection
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Renal Transplant
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
TURP care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Urinary Diversion
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Neuro
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Pain Control Measures
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Neuro Check
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
TENS unit
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Assist Lumbar Puncture
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Hyper/Hypo-thermia Blanket
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Aneurysm Care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Basal Skull Fracture
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Closed Head Fracture
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Comatose patient
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
CVA
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
DTs
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Encephalitis
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
VP Shunt
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Meningitis
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Craniotomy
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Wound Care
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Wet to Dry
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Packing
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Debridement
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Sterile Dressing
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Burn care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Pressure sore
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Decubitus staging
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Surgical wound/drain
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Irrigation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Occlusive Dressing
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Infectious Disease
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Lab Results: Blood Counts
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
HIV / AIDS care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Hepatitis care
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Fever Management
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Isolation Precautions
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Universal Precautions
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Blood Borne Pathogens
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Disposal of hazardous waste
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Particulate Respirators
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
IV Therapy
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Blood product administration
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
PRBC
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Whole Blood
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Plasma
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Platelets
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Cryoprecipitate
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Drawing blood from Central line
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Starting peripheral IV
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Central Line dressing
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Broviac
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Groshong
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Hickman
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Portacath
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Quinton
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Oncology
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Pain Control
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Nutritional Status
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Reverse Isolation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Bone Marrow Transplant
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Inpatient Chemo
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Inpatient Hospice
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Leukemia
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Pain Management
Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert
Epidural Anesthesia
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Conscious Sedation
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Narcotic Analgesia
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
PCA
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Patient Teaching
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
Family Teaching
*
1
2
3
4
Never Performed
Expert
1 is Never Performed, 4 is Expert
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*
I hereby verify that all of the above information is correct, true, and valid. If any information were to be found false, it may be grounds for immediate termination.
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