Psychiatric Care Skills Checklist Form

Items in red are REQUIRED fields.

Personal Information:
First Name:        Middle Initial:
Last Name:
Address:
City:
State:        ZIP:
Phone:
E-mail Address:
Years of Experience:

Directions for completing Skills Checklist:

The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar. Use the following KEY as a guideline:
A) Theory Only/No Experience - Didactic instruction only, no hands-on experience.
B) Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months.
C) Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.
D) Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.



A. PSYCHIATRIC    A        B        C        D
   1. Clinical Assessment/Assessment Tools  
      (a) General Admission Procedures         
      (b) Initial Nursing Assessment and Care Plan         
      (c) Initial Treatment Plan         
      (d) Neurological Vital Signs         
      (e) Nursing Diagnoses         
      (f) Nursing Reassessment/Care Plan Updating         
      (g) Suicide Risk Assessment         
      (h) Intelligence Assessment  
         (1) Wechsler Intelligence Scale (WAIS)         
         (2) Wechsler Intelligence Scale for Children         
      (i) Personality Assessment  
         1) Minnesota Mulitphasic Personality Inventory (MMPI)         
         (2) Rorschach Test         
         (3) Thematic Apperception Test (TAT)         
         (4) Child's Apperception Test (CAT)         
      (j) Informal Cognitive Status Assessment         
      (k) Mental Status Assessment         
      (l) Gestalt Test         
      (m) Stanford-Binet Test         
   2. Equipment and Procedures  
      (a) Participation in Multi-Disciplinary Staffing         
      (b) Charge Nurse Experience   Years
      (c) Charting  
         (1) Behavioristic         
         (2) Treatment/Goal Oriented         
      (d) Discharge Planning         
      (e) Patient Teaching/Education         
      (f) Psychiatric Emergency Response Team         
      (g) Psychiatric Home Health         
      (h) Rapid Tranquilization         
      (i) Cardiopulmonary Resuscitation         
      (j) Insertion/Care of Foley Catheter         
      (k) Oxygen Therapy and medication Delivery Systems  
         (1) Bag and Mask         
         (2) External CPAP         
         (3) Face Masks         
         (4) Inhalers         
         (5) Nasal Cannula         
         (6) Portable Oxygen Tanks         
         (7) Trach Collar         
      (l) Restraints, Application and Assessment of:  
         (1) Ambulatory Cuffs         
         (2) Full Restraints         
         (3) Wrist Restraints         
      (m) Group Therapy Leader         
      (n) Participation in Milieu Therapy         
      (o) Psychotherapy         
      (p) Behavior Therapy         
      (q) Relationship/Family Therapy         
      (r) Electroconvulsive Therapy         
      (s) Crisis Counseling         
      (t) Telephonic Crisis Intervention         
      (u) Suicide Precautions         
   3. Communication Skills  
      (a) Active Listening         
      (b) Questioning         
      (c) Restatement/Reflection         
      (d) Clarification         
      (e) Focusing         
      (f) Confrontation         
      (g) Summarizing         
      (h) Boundaries         
      (i) Positive Reinforcement         
      (j) Orientation Assessment         
      (k) De-escalation         
      (l) Empathizing         
      (m) Reframing Skills         
   4. Care of the Patient With:  
      (a) Depressive Disorders         
      (b) Anxiety Disorders         
      (c) Schizophrenia-Spectrum Disorders         
      (d) Personality Disorders         
      (e) Eating Disorders         
      (f) Congenital/Developmental Disorders  
         (1) Mental Retardation         
         (2) Down's Syndrome         
         (3) Cystic Fibrosis         
         (4) Cerebral Palsy         
         (5) Spina Bifida         
         (6) Autism         
         (7) Asperger's Syndrome         
         (8) Rett's Syndrome         
      (g) Degenerative Disorders  
         (1) Alzheimer's Disease         
         (2) Parkinson's Disease         
         (3) Huntington's Chorea         
      (h) Rape Victimization         
      (i) Assault/Violence         
      (j) Suicidal Behavior         
      (k) Conduct Disorder         
      (l) Separation Anxiety Disorder         
      (m) Attention Deficit Disorders (ADD/ADHD)         
      (n) Elimination Disorders (Encopresis/Enuresis)         


B. MEDICATIONS/METHODS OF DELIVERY    A        B        C        D
   1. Medications  
      (a) Antipsychotics         
      (b) Analgesics/Narcotics         
      (c) Antidepressants         
      (d) Antianxiety         
      (e) Anticonvulsants         
      (f) Anti-Parkinson         
   2. Methods of Delivery  
      (a) Intramuscular         
      (b) Oral         
      (c) Rectal         
      (d) Subcutaneous         
      (e) Unit Dose         
   3. Phlebotomy/IV Therapy  
      (a) Administration of Blood and Blood Products         
      (b) Drawing Blood from Central Line         
      (c) Drawing Venous Blood         
      (d) Management of Patient with Hyperalimentation         
      (e) Management of Patient with IV         
      (f) Starting IVs  
         (1) Angiocath         
         (2) Butterfly         
         (3) Heparin Lock         


C. LEGAL/ETHICAL    A        B        C        D
   1. Legal Rights of the Mentaly Ill         
   2. Informed Consent         
   3. Right to Refuse Treatment         
   4. Involuntary Commitment         
   5. Use of Restraints         
   6. Use of Seclusion         


D. MISCELLANEOUS    A        B        C        D
   1. AMA procedures Yes     No

Please check the boxes for each age group for which you have expertise in providing age-appropriate nursing care.

AGE SPECIFIC PRACTICE:
A) Newborn.Neonate (Birth - 30 days) D) Preschooler (3-5 years) G) Young Adults (18-39 years)
B) Infant (30 days-1 year) E) School Age Children (5-12 years) H) Middle Adults (39-64 years)
C) Toddler (1-3 years) F) Adolescents (12-18 years) I) Older Adults (64+)

EXPERIENCE WITH AGE GROUPS:
Able to adapt care to incorporate normal growth and development:
A         B         C         D         E         F         G         H         I
Able to adapt method and terminology of patient instruments to their age comprehension and maturity level:
A         B         C         D         E         F         G         H         I
Can ensure a safe environment reflecting specific needs of various age groups:
A         B         C         D         E         F         G         H         I

The information I have given is true and accurate to the best of my knowledge. I hereby authorize Professional Nursing Service to release my Psychiatric Care Skills Checklist to Client facilities of PNS in relation to consideration of employment as a Traveler with those facilities.

Yes, I agree and consent to the statement above         Date: