Clinic – Professional Nursing Service

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.

Clinical Practice

1. Administrative Skills:*

	A	B	C	D
Schedule and manage appointments
Organize and maintain patient's medical record
File medical records
Utilize electronic health records for accurate patient documentation
Demostrate telephone techniques

2. Billing & Coding:*

3. Provision of Care:*

	A	B	C	D
Obtain and analyze vital signs
Perform comprehensive physical patient assessment
Obtain and document patient history
Obtain and document patient allergies
Recognize abnormal assessment findings and intervene accordingly
Prioritize responsibilities for effective safe patient care
Utilize two patient identifiers prior to treatments, procedures, and medication administration
Utilize multiple screening tools (hearing test, vision test, developmental test)
Telephone triage procedures
Laboratory test interpretation
Radiology test interpretation
EKG interpretation
Develop and maintain nursing care plan
Determine time and time intervals
Determine start and stop times for time intervals
Determine time using military time and analog clock
Activate and participate in emergency response plan for emergency situations
Perform Basic Life Support, CPR, and Heimlich maneuver
Utilize AED for emergency situations
Initiate patient referrals to other healthcare agencies
Maintain proper body mechanics
Understand and follow physicians orders
Maintain and apply safety/risk protocols for fall precautions
Maintain and apply safety/risk protocols for suicide precautions
Perform pain assessment
Apply non-pharmacological techniques for pain when appropriate (diversion, relaxation, breathing, etc.)
Assess post-surgical patient for complications
Perform nursing interventions for end of life care
Assess and manage a variety of drains (surgical, wound, etc.)
Perform wound/pressure ulcer staging assessment and classification
Assess for drug/alcohol dependence and withdrawal

Infection Control

1.*

	A	B	C	D
Adhere to hand washing guidelines
Maintain aseptic technique
Maintain Universal Precautions
Maintain sterile technique when appropriate
Utilize Isolation Precautions when appropriate
Utilize Personal Protective Equipment when indicated
Disposal of biohazardous materials
Maintain clean environment utilizing environmental cleaning procedures

Professional Practice

1. Patient Advocacy:*

	A	B	C	D
Recognition and reporting of suspected abuse/neglect for all age groups
Demostrate assertiveness & initiate advocacy for patients
Utilize chain of command to ensure safe patient care
Abide by Advance Directives (Living Wills, Health Care Proxy, Power of Attorney for Health Care)

2. Professional Issues*

	A	B	C	D
Maintain privacy and dignity for each patient
Maintain patient confidentiality per HIPAA guidelines
Identify and respond to issues of confidentiality
Complies with Joint Commission, NPSG, CMS, and other federal/state regulations and guidelines
Report incidents as indicated and follow protocols for incidents
Report patient conditions as indicated by federal/state regulations and guidelines (abuse/neglect, communicable diseases, gunshot wound, dog bite)

3. I acknowledge and understand the Joint Commission's list of "Do Not Use Abbreviations" (4-Yes 1 -No)*

	A	B	C	D

4. Interdisciplinary Communication*

	A	B	C	D
Communicate accurately and effectively in English, both written and verbal
Communicate with patient using age and cultural appropriate methods
Respond to and initiate written communication
Recognize and respond to verbal communication
Recognize and respond to nonverbal communication
Collaborate with interdisciplinary teams for care of patient
Utilize SBAR communication
Utilize problem-solving/decision-making techniques
Give and receive reports from other healthcare professionals regarding patient care
Delegate effectively to licensed and non-licensed personnel

Laboratory

1. Specimen Collection:*

2. Laboratory testing:*

Medication Administration

1. Provision of Care:*

	A	B	C	D
Utilize 6 rights of medication administration
Utilize dosage calculation formulas for accurately determine medication dosages
Maintain medication and immunization records
Provide education to patient regarding medications
Obtain history regarding contraindications
Obtain history regarding anaphylactic/allergy reactions
Assess for therapeutic response, expected outcomes
Assess for and manage adverse reactions
Waste medications (utilize proper procedures and documentation)

2. Administer medications through a variety of routes:*

3. Types of medication administration:*

4. Immunizations:*

	A	B	C	D
Determine eligibility to receive vaccine
Provide patient education in relation to vaccines
PPD placement and reading results
Flu vaccine
Pneumococcal vaccine
Varicella
DTaP
MMR
HepA
HepB
HPV
Rotavirus
IPV
Hib
HPV
Meningococcal

Patient Education

1.*

	A	B	C	D
Identify needs for health maintenance and disease prevention
Provide instruction for health maintenance and disease prevention
Instruct individuals according to their needs
Instruct and demostrate use and care of patient equipment
Explain general office policies

Procedures

1.*

	A	B	C	D
Provide education and patient preparation for invasive procedures
Obtain patient consent for treatments and procedures
Perform time-out procedure
Provide Central line/PICC line care
Ear lavage
Placement and management of peripheral IV
Assist with Doppler exams
Assist with simple biopsy
Assist with I&D
Assist with lumbar puncture
Assist with wound debridements
Assist with Colposcopy
Assist with Urodynamic Studies
Assist with IUD insertions
Assist with bone marrow biopsy
Assist with setting of simple bone fractures
Assist with suturing
Removal of sutures/staples
Application of casts/splints
Sterile dressing changes
Non-sterile dressing changes
Oxygen administration
Accessing venous ports
Measurement and application of anti-embolic stockings
Instruct/educate patient to use incentive spirometer
Place and manage nasogastric tube
Perform oral and nasopharyngeal suctioning
Insert and remove indwelling urinary catheter
Insert and remove straight urinary catheter

Patient Care Settings

1.*

	A	B	C	D
General Clinic (more than 5 MDs in practice)
General Clinic (less than 5 MDs in practice)
General Internal Medicine
Allergy Clinic
Endocrinology
Gastroenterology
Health/Wellness Screening
OB/GYN
Occupational Health
Oncology
Orthopedics
Pediatrics
Rehab Clinic
Rheumatology
Surgical Practice
Utilization Review/Case Management

Age Specific:

Please indicate the frequency with which you provide care for each age group:*

Date*

	A	B	C	D
ICD-9 Coding
ICD-10 Coding
CPT Coding
Insurance billing

	A	B	C	D
Venipuncture
Central line blood draws
Capillary puncture
Throat specimen collection
Urine specimen collection
Stool specimen collection
Suptum specimen collection
Tissue specimen collection

	A	B	C	D
Use methods for quality testing
Perform urinalysis testing
Perform glucometer testing
Perform pediatric screenings (PKU)

	A	B	C	D
Topical
Oral
Intradermal injection
Intramuscular injection
Subcutaneous injection
IV push
IV infusion

	A	B	C	D
Blood transfusion
Chemotherapy
Insulin
Drug overdose treatment
Antibiotics
Analgesics
Narcotics
IV Fluids
Muscle relaxers
Anit-anxiety
Sedatives
Anticoagulant therapy

	A	B	C	D
Infant (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)

Clinic Skills Checklist