Ambulatory Skills Checklist "*" indicates required fields Name* First Last Email* Phone*Years Experience in Clinical Specialty:*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.GENERAL SKILLS1. General*ABCDStandard PrecautionsIsolation PrecautionsAdult Respiratory/ Cardiac ArrestPediatric Respiratory/Cardiac ArrestCrash CartsDefibrillatorsPatient/ Family EducationAdmit and Assess PatientsAutomated Med Dispensing SystemsElectronic DocumentationObtaining Cultures (Blood, Sputum, Swab, Urine)Advance DirectivesCollect Appropriate DataDischarge TeachingPreoperative TeachingPatient PrepCARDIOVASCULAR1. General*ABCDAssess Heart TonesBedside Tele MonitoringInterpretation of Coagulation StudiesPerform Pulse/ Circulation ChecksPre-Post Op Pacemaker CarePULMONARY1. GENERAL*ABCDAssess Breath SoundsApply OxygenInterpret ABGsThoracentesisOximetryNEUROLOGY1. General*ABCDAssess Neurological SignsEpiduralsSelective Nerve Root BlocksAssess Level of ConsciousnessGI1. General*ABCDInsertion/ Monitoring NG TubesAssessmentFlexible SigmoidoscopyHemorrhoid BandingLiver BiopsyParacentesisLap Band SurgeryGU1. General*ABCDApplication of Soft Limb RestraintsBladder BiopsyCystoscopyUrethral DilationNephrostomyKidney BiopsySuprapubic CatheterProstate BiopsyENDOCRINE1. General*ABCDHemovac/Davol Suction PumpCare of Diabetic PatientDiabetic TeachingENT AND MOUTH1. General*ABCDProsthodontics -Restorative DentistryMouth BiopsyMyringotomyMaxillofacial ProstheticsNose BiopsyThyroid Aspirate BiopsyFiberoptic LaryngoscopyTonsillectomyWOUNDS/ INTEGUMENT1. General*ABCDReporting on Assigned PatientsApplication of Burn DressingDressing ChangesDebridement of WoundWound CareWound VacOB/ GYN1. General*ABCDElectrodesiccation and Curettage (ED7C)Assist with In-Office ProceduresORTHO1. General*ABCDArthrocentesisExternal Hardware and Pin CareArthroscopyOpen Reduction and Internal FixationClosed Reduction and Internal FixationTrigger Point InjectionsPLASTICS1. General*ABCDRhinoplastyLiposuctionNipple ReconstructionMOHS RepairsBlepharoplastyMole/ Cyst RemovalGENERAL MEDICATIONS/ THERAPEUTIC INTERVENTIONS1. General*ABCDAdminister IM and SQ MedicationsAdminister Inhalation MedicationsAdminister PO MedicationsBladder Irrigation and InstallationNeedleless SystemChemotherapyIV THERAPY1. General*ABCDInfusion PumpsPeripheral IV InsertionSyringe PumpsVascular Access Devices Care/ MaintenanceAdminister IV MedicationsOXYGEN ADMINISTRATION1. General*ABCDAmbu-BagNasal CannulaNon-Rebreather MaskVenti MaskFace MaskNUTRITIONAL THERAPY1. General*ABCDLipidsTPNProcalamineEnteral AdministrationPAIN MANAGEMENT/ ANESTHESIA1. General*ABCDImplantable Narcotic PumpModerate SedationEpiduralSpinalLocalGeneralAxillary BlockBier BlockGENERAL PROCEDURES/ EQUIPMENT1. General*ABCDApply Immobilizers (clavicle, knee, etc.)Assist with Code ResuscitationAssist with Lumbar PunctureLaserDermabrasionDrain RemovalIncision and DrainageNGT InsertionPatch TestPunch BiopsyShave BiopsyProcedure Set UpRemove External Fixators with PinScrubScrew-Hardware RemovalSet-Up/ Assist SuturingStaple RemovalSuture RemovalFoley/ Straight Catheter - MaleFoley/ Straight Catheter - FemaleTENS UnitUse of DopplerSPECIMEN COLLECTIONS1. General*ABCDVenipunctureClean Catch UrineSterile Urine CollectionStoolSputumButterfly StickCentral Line DrawCLINICAL SETTINGS1. General*ABCDSurgi-CenterOut Patient ClinicPhysician OfficeAmbulatory Surgery ClinicAge Specific:Please indicate the frequency with which you provide care for each age group:*ABCDInfant (Birth to 1 year)Toddler (1-3 years)Pre-school (3-6 years)School Age (6-12 years)Adolescent ( 12-18 years)Young Adult ( 18-30 years)Mature Adult (30-60 years)Elderly (>60 years)* The information I have given is true and accurate to the best of my knowledge. I hereby authorize Professional Nursing Service to release my Skills Checklist to Client facilities of PNS in relation to consideration of employment as a Traveler with those facilities.Date* MM slash DD slash YYYY
