Medical/Surgical Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information HiddenOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security Number Email(Required) HiddenDate MM slash DD slash YYYY Key To Competency Levels0 – No Experience 1 – Minimal experience, need review and supervision, have performed at least once 2 – Comfortable performing with resource available 3 – Competent to perform independently and safely 4 – Expert, able to act as resource to othersNuerologyCommunicates and obtains information while respecting the rights and privacy and confidentiality of information.(Required) 0 1 2 3 4 Complies with nursing staff responsibility include in the hospital policy related to Organ Donation.(Required) 0 1 2 3 4 Involves the patient and family and respects their role in determining the nature of care to be provided, including Advanced Directives.(Required) 0 1 2 3 4 Meets patient and families needs regarding communication, including interpreter services.(Required) 0 1 2 3 4 Provides accurate information to patient and families in a timely manner(Required) 0 1 2 3 4 Patients RightsNeuro Assessment/Neuro Vitals(Required) 0 1 2 3 4 Seizure Precautions(Required) 0 1 2 3 4 Stryker Frame(Required) 0 1 2 3 4 Crutchfield Tongs(Required) 0 1 2 3 4 Halo Traction(Required) 0 1 2 3 4 Immobilization Techniques(Required) 0 1 2 3 4 Care of Patient with: Spinal Cord Injury(Required) 0 1 2 3 4 Care of Patient with: Pre/Post Neurological Surgery(Required) 0 1 2 3 4 Care of Patient with: CNS Infections(Required) 0 1 2 3 4 Care of Patient with: Degenerative Diseases of the Nervous System(Required) 0 1 2 3 4 Care of Patient with: Drug Overdose(Required) 0 1 2 3 4 Care of Patient with: Acute Head injury(Required) 0 1 2 3 4 Care of Patient with: Cerebral Aneurysm(Required) 0 1 2 3 4 Care of Patient with: Acute/Chronic C.V.A/T.I.A.(Required) 0 1 2 3 4 Care of Patient with: Rehabilitation of the Neuro patient(Required) 0 1 2 3 4 Managing patient with epidural catheter(Required) 0 1 2 3 4 Managing patient with spinal precautions(Required) 0 1 2 3 4 CardiovascularCardio pulmonary arrests(Required) 0 1 2 3 4 Running code 99(Required) 0 1 2 3 4 Caring for 48+ hour post-op Open Heart patient(Required) 0 1 2 3 4 Caring for a pacemaker patient(Required) 0 1 2 3 4 Pre/post-op angioplasty(Required) 0 1 2 3 4 Post-op vascular surgery patients (i.e. aneurysms)(Required) 0 1 2 3 4 Angina (acute and chronic)(Required) 0 1 2 3 4 Ability to interpret cardiac rhythms(Required) 0 1 2 3 4 Care of patient with: Valvular disease(Required) 0 1 2 3 4 Care of patient with: Central lines(Required) 0 1 2 3 4 Assessing and treating orthostatic BP(Required) 0 1 2 3 4 Assessing abnormal heart tones(Required) 0 1 2 3 4 Medication and AdministrationKnowledge of Indications, Actions, Contraindications, Side Effects, Methods of Administration, Calculation of Dose, Rate of Infusion, caring for and monitoring patient receiving the following:Acetaminophen(Required) 0 1 2 3 4 Acetylsalicylic Acid(Required) 0 1 2 3 4 Antibiotics(Required) 0 1 2 3 4 Beta blockers(Required) 0 1 2 3 4 Calcium Channel Blockers(Required) 0 1 2 3 4 Cimetidine(Required) 0 1 2 3 4 Codeine(Required) 0 1 2 3 4 Dexamethasone(Required) 0 1 2 3 4 Diazepam(Required) 0 1 2 3 4 Digoxin(Required) 0 1 2 3 4 Duramorph(Required) 0 1 2 3 4 Furosemide(Required) 0 1 2 3 4 Heparin(Required) 0 1 2 3 4 Insulin(Required) 0 1 2 3 4 Lorazepam(Required) 0 1 2 3 4 Morphine(Required) 0 1 2 3 4 Naloxone(Required) 0 1 2 3 4 Nitroglycerine(Required) 0 1 2 3 4 Phenytoin(Required) 0 1 2 3 4 Potassium Chloride(Required) 0 1 2 3 4 Theophylline(Required) 0 1 2 3 4 Verapamil(Required) 0 1 2 3 4 Warfarin(Required) 0 1 2 3 4 Inhalers(Required) 0 1 2 3 4 Oral Medications(Required) 0 1 2 3 4 Suppositories: Vaginal(Required) 0 1 2 3 4 Suppositories: Rectal(Required) 0 1 2 3 4 Ordering Meds(Required) 0 1 2 3 4 PulmonaryAssessment of breath sounds(Required) 0 1 2 3 4 Assist with set-up maintenance of chest tubes(Required) 0 1 2 3 4 Administer oxygen (nasal canula, mask, endotracheal)(Required) 0 1 2 3 4 Oxygen saturation monitor(Required) 0 1 2 3 4 Use of chest drainage systems(Required) 0 1 2 3 4 Care of patient with: Pulmonary emboli(Required) 0 1 2 3 4 Care of patient with: Tracheostomy(Required) 0 1 2 3 4 Care of patient with: Pre/post thoracic surgery(Required) 0 1 2 3 4 Care of patient with: Asthma(Required) 0 1 2 3 4 Care of patient with: COPD(Required) 0 1 2 3 4 Care of patient with: CHF(Required) 0 1 2 3 4 Care of patient with: Tuberculosis(Required) 0 1 2 3 4 Nasal Tracheal Suctioning(Required) 0 1 2 3 4 Changing Tracheostomy(Required) 0 1 2 3 4 Instructing patient in use of incent. spirometer(Required) 0 1 2 3 4 GastrointestinalAssessment of bowel sounds(Required) 0 1 2 3 4 Identification of abnormalities(Required) 0 1 2 3 4 Stool tests(Required) 0 1 2 3 4 nsert/Maintain Feeding tubes/NG tubes(Required) 0 1 2 3 4 Administering Tube Feedings(Required) 0 1 2 3 4 Checking Tube Feeding Residuals(Required) 0 1 2 3 4 Inserting/maintaining intermittent & continuous suction NG tubes(Required) 0 1 2 3 4 Checking tube feeding and NG tube placement(Required) 0 1 2 3 4 Care of acute GI bleed(Required) 0 1 2 3 4 Ileostomy/Colostomy and drain care(Required) 0 1 2 3 4 Abdominal wounds or infections(Required) 0 1 2 3 4 Pre/post-op GI Surgery(Required) 0 1 2 3 4 Dehiscence(Required) 0 1 2 3 4 Care of patient on Total Parenteral Nutrition(Required) 0 1 2 3 4 Genitourinary / RenalAbility to insert/maintain urinary drainage tubes(Required) 0 1 2 3 4 Care of patient with: Acute renal failure(Required) 0 1 2 3 4 Care of patient with: Chronic renal failure(Required) 0 1 2 3 4 Care of patient with: Post renal/genitourinary surgery(Required) 0 1 2 3 4 Caring for a patient recovering from Peritoneal dialysis(Required) 0 1 2 3 4 Caring for a patient recovering from Hemodialysis(Required) 0 1 2 3 4 Assessment of fluid and electrolyte problems(Required) 0 1 2 3 4 Knowledge of UA values(Required) 0 1 2 3 4 Managing urostomy(Required) 0 1 2 3 4 Managing suprapubic catheter(Required) 0 1 2 3 4 Placing condom catheter(Required) 0 1 2 3 4 Collecting specimens(Required) 0 1 2 3 4 EndocrineCaring for a diabetic patient(Required) 0 1 2 3 4 Administration of IV insulin drip(Required) 0 1 2 3 4 Capillary blood glucose checks(Required) 0 1 2 3 4 Hormone therapy(Required) 0 1 2 3 4 OncologyCaring for AIDS patient(Required) 0 1 2 3 4 Isolation/Universal precautions(Required) 0 1 2 3 4 Pain management(Required) 0 1 2 3 4 Mixing/Administering chemo agents(Required) 0 1 2 3 4 MusculoskeletalTraction(Required) 0 1 2 3 4 Braces(Required) 0 1 2 3 4 Casts(Required) 0 1 2 3 4 Collars(Required) 0 1 2 3 4 Slings(Required) 0 1 2 3 4 Splints(Required) 0 1 2 3 4 Skeletal traction(Required) 0 1 2 3 4 Skin traction(Required) 0 1 2 3 4 Using T.E.N.S. unit(Required) 0 1 2 3 4 Beds i.e. Clinitron, Roto Rest(Required) 0 1 2 3 4 Total knee replacement(Required) 0 1 2 3 4 Total hip replacement(Required) 0 1 2 3 4 Crutch walking/walkers(Required) 0 1 2 3 4 Care of patient with: Joint disorders(Required) 0 1 2 3 4 Care of patient with: Bone disorders(Required) 0 1 2 3 4 Care of patient with: Amputation(Required) 0 1 2 3 4 Caring for patient on CPM(Required) 0 1 2 3 4 MicellaneousPain management(Required) 0 1 2 3 4 Burn patients(Required) 0 1 2 3 4 Inserting IV’s/IV therapy(Required) 0 1 2 3 4 Set-up for Cut Down(Required) 0 1 2 3 4 Performing complex dressing changes(Required) 0 1 2 3 4 Administration of blood and blood products(Required) 0 1 2 3 4 Administering and monitoring IV Anticoagulants(Required) 0 1 2 3 4 Obtaining peripheral venous blood(Required) 0 1 2 3 4 Obtaining blood from central venous line(Required) 0 1 2 3 4 Knowledge of Serum Lab Values: Chem 7, Chem 10(Required) 0 1 2 3 4 Knowledge of Serum Lab Values: CBC(Required) 0 1 2 3 4 Knowledge of Serum Lab Values: Serum Drug Levels(Required) 0 1 2 3 4 IV Therapy(Required) 0 1 2 3 4 Care of drains/tubes (i.e. hemovac, etc.)(Required) 0 1 2 3 4 Monitoring and assessing I & O(Required) 0 1 2 3 4 Using PCA System(Required) 0 1 2 3 4 Using SCD or Venidyne Devices(Required) 0 1 2 3 4 Using PICC, Hickman, Central Line(Required) 0 1 2 3 4 Providing for safe patient environment(Required) 0 1 2 3 4 Experience AreasMedical/Surgical(Required) Yes No Type: Years / Months Telemetry/Stepdown(Required) Yes No Type: Years / Months Ortho(Required) Yes No Type: Years / Months Rehabilitation(Required) Yes No Type: Years / Months Mother - Baby(Required) Yes No Type: Years / Months Oncology(Required) Yes No Type: Years / Months Neurology(Required) Yes No Type: Years / Months Pediatrics(Required) Yes No Type: Years / Months Urology(Required) Yes No Type: Years / Months Skilled(Required) Yes No Type: Years / Months Hospice(Required) Yes No Type: Years / Months General Medicine(Required) Yes No Type: Years / Months General Surgery(Required) Yes No Type: Years / Months Charge Experience(Required) Yes No Type: Years / Months IV Certified(Required) Yes No Type: Years / Months Other(Required) Yes No Type: Years / Months AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. 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