MedSurg Skills Assessment

Name *

First Name Last Name
Date *

Month Day Year
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
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? *
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

Cardiovascular

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

Assessments

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

Endocrine

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

Pulmonary

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

GastroIntestinal

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

Renal / Genitalurinary

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

Neuro

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

Wound Care

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

Infectious Disease

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=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

1 is Never Performed, 4 is Expert

PRBC *

	1	2	3	4

1 is Never Performed, 4 is Expert

Whole Blood *

	1	2	3	4

1 is Never Performed, 4 is Expert

Plasma *

	1	2	3	4

1 is Never Performed, 4 is Expert

Platelets *

	1	2	3	4

1 is Never Performed, 4 is Expert

Cryoprecipitate *

	1	2	3	4

1 is Never Performed, 4 is Expert

Drawing blood from Central line *

	1	2	3	4

1 is Never Performed, 4 is Expert

Starting peripheral IV *

	1	2	3	4

1 is Never Performed, 4 is Expert

Central Line dressing *

	1	2	3	4

1 is Never Performed, 4 is Expert

Broviac *

	1	2	3	4

1 is Never Performed, 4 is Expert

Groshong *

	1	2	3	4

1 is Never Performed, 4 is Expert

Hickman *

	1	2	3	4

1 is Never Performed, 4 is Expert

Portacath *

	1	2	3	4

1 is Never Performed, 4 is Expert

Quinton *

	1	2	3	4

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 Management

Please select the answer that most accurately describes your proficiency level. 1=Never ; 2=Familiar ; 3=Experience ; 4=Expert

Place check mark in box to continue: *

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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