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

PCA pump *

	1	2	3	4
Never Performed					Expert

Colostomy *

	1	2	3	4
Never Performed					Expert

Ileostomy *

	1	2	3	4
Never Performed					Expert

Aneurysms *

	1	2	3	4
Never Performed					Expert

Isolation *

	1	2	3	4
Never Performed					Expert

Femoral-Popliteal Bypass *

	1	2	3	4
Never Performed					Expert

Thoracic Surgery *

	1	2	3	4
Never Performed					Expert

Carotid Endarterectomy *

	1	2	3	4
Never Performed					Expert

CVA *

	1	2	3	4
Never Performed					Expert

Spinal Cord Injury *

	1	2	3	4
Never Performed					Expert

Craniotomy *

	1	2	3	4
Never Performed					Expert

DT's *

	1	2	3	4
Never Performed					Expert

Overdose *

	1	2	3	4
Never Performed					Expert

Burns *

	1	2	3	4
Never Performed					Expert

GI bleeds *

	1	2	3	4
Never Performed					Expert

HIV / AIDS *

	1	2	3	4
Never Performed					Expert

ARDS *

	1	2	3	4
Never Performed					Expert

Near Drowning *

	1	2	3	4
Never Performed					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

Blood Pressure interpret *

	1	2	3	4
Never Performed					Expert

12-Lead EKG *

	1	2	3	4
Never Performed					Expert

Telemetry Interpret *

	1	2	3	4
Never Performed					Expert

Telemetry Lead Placement *

	1	2	3	4
Never Performed					Expert

Doppler use *

	1	2	3	4
Never Performed					Expert

Heart murmur *

	1	2	3	4
Never Performed					Expert

Pulse checks *

	1	2	3	4
Never Performed					Expert

PaceMaker *

	1	2	3	4
Never Performed					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

Respiratory Assessment *

	1	2	3	4
Never Performed					Expert

GI Assessment *

	1	2	3	4
Never Performed					Expert

GU Assessment *

	1	2	3	4
Never Performed					Expert

Nutritional Assessment *

	1	2	3	4
Never Performed					Expert

Mental Assessment *

	1	2	3	4
Never Performed					Expert

Musculoskeletal Assessment *

	1	2	3	4
Never Performed					Expert

Neuro Assessment *

	1	2	3	4
Never Performed					Expert

Integumentary Assessment *

	1	2	3	4
Never Performed					Expert

Pain Assessment *

	1	2	3	4
Never Performed					Expert

Psychosocial Assessment *

	1	2	3	4
Never Performed					Expert

Wound Assessment *

	1	2	3	4
Never Performed					Expert

Lab value Assessment *

	1	2	3	4
Never Performed					Expert

Vital Signs Assessment *

	1	2	3	4
Never Performed					Expert

Medication Effects / Side Effects *

	1	2	3	4
Never Performed					Expert

Drug Interatctions *

	1	2	3	4
Never Performed					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

Insulin admin *

	1	2	3	4
Never Performed					Expert

Insulin site rotation *

	1	2	3	4
Never Performed					Expert

S/S of hypo/hyper-glycemia *

	1	2	3	4
Never Performed					Expert

Urine Testing *

	1	2	3	4
Never Performed					Expert

Blood testing *

	1	2	3	4
Never Performed					Expert

Skin/Foot care *

	1	2	3	4
Never Performed					Expert

Excercise/activity/rest *

	1	2	3	4
Never Performed					Expert

Sick day routine *

	1	2	3	4
Never Performed					Expert

Addison's Disease *

	1	2	3	4
Never Performed					Expert

Pituitary Disorders *

	1	2	3	4
Never Performed					Expert

Graves Disease *

	1	2	3	4
Never Performed					Expert

Hypo/Hyper-thyroidism *

	1	2	3	4
Never Performed					Expert

Thyroidectomy *

	1	2	3	4
Never Performed					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

Oralpharyngeal Suction *

	1	2	3	4
Never Performed					Expert

Nasotracheal Suction *

	1	2	3	4
Never Performed					Expert

Tracheostomy Care *

	1	2	3	4
Never Performed					Expert

Trach Suction *

	1	2	3	4
Never Performed					Expert

Airway Management *

	1	2	3	4
Never Performed					Expert

Sputum collection *

	1	2	3	4
Never Performed					Expert

Chest Physiotherapy *

	1	2	3	4
Never Performed					Expert

Incentive Spirometry *

	1	2	3	4
Never Performed					Expert

Oxygen Therapy *

	1	2	3	4
Never Performed					Expert

Pulse Oximetry *

	1	2	3	4
Never Performed					Expert

Ventilator care *

	1	2	3	4
Never Performed					Expert

Chest Tube Care *

	1	2	3	4
Never Performed					Expert

Inhaler use *

	1	2	3	4
Never Performed					Expert

Pulmonaide use *

	1	2	3	4
Never Performed					Expert

Postural Drainage/Percussion *

	1	2	3	4
Never Performed					Expert

Assist with ET intubation *

	1	2	3	4
Never Performed					Expert

Breathing Exercises *

	1	2	3	4
Never Performed					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

NG suction *

	1	2	3	4
Never Performed					Expert

T-Tube *

	1	2	3	4
Never Performed					Expert

Gastrostomy *

	1	2	3	4
Never Performed					Expert

Jejunostomy *

	1	2	3	4
Never Performed					Expert

Irrigation *

	1	2	3	4
Never Performed					Expert

Admin of Tube Feeding *

	1	2	3	4
Never Performed					Expert

Salem Sump Suction *

	1	2	3	4
Never Performed					Expert

Manuel Disimpaction *

	1	2	3	4
Never Performed					Expert

Digital Rectal Exam *

	1	2	3	4
Never Performed					Expert

JP Drain *

	1	2	3	4
Never Performed					Expert

Hemovac *

	1	2	3	4
Never Performed					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

Foley Removal *

	1	2	3	4
Never Performed					Expert

Foley Irrigation *

	1	2	3	4
Never Performed					Expert

3-way foley cath *

	1	2	3	4
Never Performed					Expert

Suprabuic Cath *

	1	2	3	4
Never Performed					Expert

Nephrostomy Tube Irrigation *

	1	2	3	4
Never Performed					Expert

Peritoneal Dialysis *

	1	2	3	4
Never Performed					Expert

Condom Cath *

	1	2	3	4
Never Performed					Expert

Bladder Training *

	1	2	3	4
Never Performed					Expert

Specimin Collection *

	1	2	3	4
Never Performed					Expert

Renal Transplant *

	1	2	3	4
Never Performed					Expert

TURP care *

	1	2	3	4
Never Performed					Expert

Urinary Diversion *

	1	2	3	4
Never Performed					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

Neuro Check *

	1	2	3	4
Never Performed					Expert

TENS unit *

	1	2	3	4
Never Performed					Expert

Assist Lumbar Puncture *

	1	2	3	4
Never Performed					Expert

Hyper/Hypo-thermia Blanket *

	1	2	3	4
Never Performed					Expert

Aneurysm Care *

	1	2	3	4
Never Performed					Expert

Basal Skull Fracture *

	1	2	3	4
Never Performed					Expert

Closed Head Fracture *

	1	2	3	4
Never Performed					Expert

Comatose patient *

	1	2	3	4
Never Performed					Expert

CVA *

	1	2	3	4
Never Performed					Expert

DTs *

	1	2	3	4
Never Performed					Expert

Encephalitis *

	1	2	3	4
Never Performed					Expert

VP Shunt *

	1	2	3	4
Never Performed					Expert

Meningitis *

	1	2	3	4
Never Performed					Expert

Craniotomy *

	1	2	3	4
Never Performed					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

Packing *

	1	2	3	4
Never Performed					Expert

Debridement *

	1	2	3	4
Never Performed					Expert

Sterile Dressing *

	1	2	3	4
Never Performed					Expert

Burn care *

	1	2	3	4
Never Performed					Expert

Pressure sore *

	1	2	3	4
Never Performed					Expert

Decubitus staging *

	1	2	3	4
Never Performed					Expert

Surgical wound/drain *

	1	2	3	4
Never Performed					Expert

Irrigation *

	1	2	3	4
Never Performed					Expert

Occlusive Dressing *

	1	2	3	4
Never Performed					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

HIV / AIDS care *

	1	2	3	4
Never Performed					Expert

Hepatitis care *

	1	2	3	4
Never Performed					Expert

Fever Management *

	1	2	3	4
Never Performed					Expert

Isolation Precautions *

	1	2	3	4
Never Performed					Expert

Universal Precautions *

	1	2	3	4
Never Performed					Expert

Blood Borne Pathogens *

	1	2	3	4
Never Performed					Expert

Disposal of hazardous waste *

	1	2	3	4
Never Performed					Expert

Particulate Respirators *

	1	2	3	4
Never Performed					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

PRBC *

	1	2	3	4
Never Performed					Expert

Whole Blood *

	1	2	3	4
Never Performed					Expert

Plasma *

	1	2	3	4
Never Performed					Expert

Platelets *

	1	2	3	4
Never Performed					Expert

Cryoprecipitate *

	1	2	3	4
Never Performed					Expert

Drawing blood from Central line *

	1	2	3	4
Never Performed					Expert

Starting peripheral IV *

	1	2	3	4
Never Performed					Expert

Central Line dressing *

	1	2	3	4
Never Performed					Expert

Broviac *

	1	2	3	4
Never Performed					Expert

Groshong *

	1	2	3	4
Never Performed					Expert

Hickman *

	1	2	3	4
Never Performed					Expert

Portacath *

	1	2	3	4
Never Performed					Expert

Quinton *

	1	2	3	4
Never Performed					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

Nutritional Status *

	1	2	3	4
Never Performed					Expert

Reverse Isolation *

	1	2	3	4
Never Performed					Expert

Bone Marrow Transplant *

	1	2	3	4
Never Performed					Expert

Inpatient Chemo *

	1	2	3	4
Never Performed					Expert

Inpatient Hospice *

	1	2	3	4
Never Performed					Expert

Leukemia *

	1	2	3	4
Never Performed					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

Conscious Sedation *

	1	2	3	4
Never Performed					Expert

Narcotic Analgesia *

	1	2	3	4
Never Performed					Expert

PCA *

	1	2	3	4
Never Performed					Expert

Patient Teaching *

	1	2	3	4
Never Performed					Expert

Family Teaching *

	1	2	3	4
Never Performed					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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