Urgent Care & Clinic Skills Checklist

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Personal Information

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Overall Score

Out of 4

Name(Required)

First Middle Last

Last 4 Digits of Social Security Number

Email(Required)

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Date

Proficiency Scale

1 – No Experience
2 – Need Training
3 – Able to perform with supervision
4 – Able to perform independently

CARDIOVASCULAR

1. Assessment

Auscultation/Irregular Heart Sounds(Required)

Peripheral Edema(Required)

PQRST Assessment(Required)

3. Equipment & Procedures

EKG(Required)

Lab Tests (Cardiac Enzymes, Troponin, BNP)(Required)

4. Interpretation of Labs/Tests

Arrhythmia Interpretation(Required)

12-Lead Set Up(Required)

12-Lead Basic Interpretation(Required)

Defibrillation(Required)

External Pacer(Required)

5. Care of the Patient with

Chest Pain/ACS(Required)

Arrhythmias(Required)

CHF(Required)

AED(Required)

Cardiac Arrest/CPR(Required)

6. Medications

Nitroglycerin(Required)

Morphine(Required)

Heparin(Required)

ALS (Epinephrine, Atropine, Anti-Arrhythmics)(Required)

PULMONARY

1. Assessment

Abnormal Breath Sounds (Wheezing, Stridor, Crackles)(Required)

Abnormal Breathing Pattern (Rapid, Labored, Slow)(Required)

2. Interpretation of Lab/Tests

Pulse Oximetry(Required)

ABGs(Required)

3. Equipment & Procedures

Oxygen Therapy (Nasal Cannula, Face Mask)(Required)

Manual Resuscitation Bag (MRB, Ambu Bag)(Required)

Metered-Dose Inhaler (MDI)(Required)

Nebulizers(Required)

4. Care of the Patient with

Aspiration(Required)

Asthma/Reactive Airway Disease(Required)

COPD(Required)

Pneumonia(Required)

Pulmonary Edema(Required)

Pulmonary Embolism(Required)

5. Pulmonary Embolism

Bronchodilators(Required)

Steroids(Required)

Diuretics(Required)

NEUROLOGICAL

1. Assessment

Signs & Symptoms of Stroke(Required)

Altered LOC(Required)

2. Equipment & Procedures

Assist with Lumbar Puncture(Required)

Cervical Collar(Required)

Spinal Immobilization(Required)

3. Care of the Patient with

Head Injury(Required)

Meningitis(Required)

Migraine(Required)

Seizures(Required)

TIA/Stroke(Required)

4. Medications

Imitrex (Sumatriptan Succinate)(Required)

Phenobarbitol(Required)

Dilantin (Phenytoin)(Required)

Depakote(Required)

Analgesics(Required)

ORTHOPEDICS

1. Assessment

Range of Motion(Required)

Color, Warmth, Movement, Sensation(Required)

Fracture/Dislocation(Required)

2. Equipment & Procedures

Apply Splints(Required)

Assist with Casting(Required)

Assist with Reduction of Dislocation(Required)

Spinal Immobilization(Required)

Transfer Boards(Required)

3. Care of the Patient with

Cast/Splint(Required)

Dislocation(Required)

External Appliance(Required)

Sprain/Fracture(Required)

4. Medications

Analgesia/Sedation(Required)

GASTROINTESTINAL

1. Assessment

Bowel Sounds(Required)

Distention(Required)

Fluid Balance(Required)

Nutritional Status(Required)

2. Equipment & Procedures

Enemas(Required)

Gastric Lavage(Required)

G-Tubes(Required)

NG Tubes(Required)

3. Care of the Patient with

Colostomy(Required)

Constipation/Impaction(Required)

Diarrhea(Required)

G-Tube (Reinsertion/Replacement)(Required)

Nausea/Vomiting(Required)

4. Medications

Ipecac(Required)

Charcoal(Required)

Antiemetics(Required)

Antispasmodics(Required)

RENAL/GENITOURINARY

1. Assessment

Fluid Status(Required)

Shunt/Fistula (Thrill/Bruit)(Required)

2. Interpretation of Labs

BUN/Creatinine/Electrolytes(Required)

3. Equipment & Procedures

Urine Dipstick/C&S(Required)

Placement & Management of Bladder Catheters(Required)

4. Care of the Patient with

Pyelonephritis/UTI(Required)

Obstruction(Required)

Renal Calculi(Required)

Renal Trauma(Required)

Testicular Torsion(Required)

Priapism(Required)

5.Medications

Antibiotics(Required)

ENDOCRINE/METABOLIC

1. Assessment

Hypo/Hyperglycemia(Required)

2. Interpretation of Labs

Blood Glucose(Required)

Urine Ketones(Required)

3. Equipment & Procedures

Bedside Blood Glucose Monitoring(Required)

4. Care of the Patient with

Hypoglycemia/Insulin Shock(Required)

Hyperglycemia/DKA(Required)

5. Medications

Dextrose(Required)

Insulin(Required)

Oral Hypoglycemics(Required)

EENT

1. Assessment

Visual Acuity(Required)

Foreign Body(Required)

Enlarged Tonsils(Required)

2. Equipment & Procedures

Ear Irrigation/Removal Foreign Body(Required)

Eye Injury/Foreign Body/Detached Retina(Required)

Assist with Removal of Nasal Foreign Body(Required)

Epistaxis(Required)

Set Up/Assist Cautery(Required)

Set Up Slit Lamp(Required)

3. Medications

Silver Nitrate(Required)

Liquid Cocaine(Required)

Anti-Hypertensives(Required)

INFECTIOUS DISEASE

1. Assessment

Communicable Disease(Required)

Interpret Culture Results(Required)

2. Equipment & Procedures

Obtain Cultures(Required)

Fever Management(Required)

Isolation(Required)

Reverse Isolation/Hepa Filter(Required)

Use of Personal Protective Equipment(Required)

3. Care of the Patient with

Communicable Disease(Required)

Infectious Disease(Required)

Immunosuppression/Neutropenia(Required)

4. Medications

Antibiotics(Required)

Antivirals(Required)

WOUND MANAGEMENT

Burn Care(Required)

Dressing Change(Required)

Ostomy Care(Required)

Wound Repair (Staples/Sutures, etc.)(Required)

PAIN MANAGEMENT

Assessment of Pain Level/Use of Pain Scale(Required)

Assessment of Response to Pain Management Interventions(Required)

Monitoring of Patients after Pain Medication(Required)

Comfort Care(Required)

Moderate Sedation(Required)

PSYCHIATRIC

1. Assessment

Behavior(Required)

Drug/ETOH(Required)

Risk for Violence(Required)

2. Equipment & Procedures

Managing Threatening/Violent Behavior(Required)

Psychiatric Hold(Required)

3. Care of the Patient with

Drug OD(Required)

ETOH OD(Required)

Depression/Anxiety(Required)

Restraints(Required)

Suicide Risk(Required)

4. Medications

Antipsychotics/Antidepressants(Required)

Reversal Agents(Required)

WOMEN'S HEALTH

1. Assessment

Vaginal Bleeding(Required)

Doppler/Fetal Heart Tones(Required)

Ectopic Pregnancy(Required)

2. Equipment & Procedures

Obtain Cultures(Required)

Pelvic Tray(Required)

3. Care of the Patient with

Ectopic Pregnancy(Required)

Hemorrhage(Required)

Pelvic Inflammatory Disease(Required)

Placenta Abruptio/Previa(Required)

Precipitous Delivery(Required)

Pregnancy-Induced Hypertension(Required)

Spontaneous Abortion(Required)

PEDIATRICS

Child Abuse Recognition/Reporting(Required)

Shaken Baby Syndrome(Required)

Obtaining Consent to Treat(Required)

1. Assessment

Normal VS for age groups(Required)

Use of Dynamap/Doppler Leg Cuffs for B/P(Required)

Failure to Thrive(Required)

2. Equipment & Procedures

Assist with Fracture Stabilization(Required)

Cooling/Warming Measures(Required)

Draw Labs (Venous/Butterfly)(Required)

Ear Care-Assist with Cleaning/Wash, Insert Ear Drops(Required)

IM/SQ Medications in Pediatric Patients(Required)

Obtain RSV Culture(Required)

Obtain Urine Culture (Cath/Bag)(Required)

Lumbar Puncture(Required)

Papoose Board/Therapeutic Hold(Required)

Start IV in Pediatric Patient(Required)

3. Care of the Pediatric Patient with

Abdominal Pain(Required)

Aspiration(Required)

Asthma/Reactive Airway Disease(Required)

Burns(Required)

Dehydration(Required)

Epiglottitis(Required)

Fever(Required)

Foreign Object(Required)

Fracture(Required)

Head Injury(Required)

Hypo/Hyperglycemia(Required)

Hypo/Hyperthermia(Required)

Lacerations(Required)

Near Drowning(Required)

Nursemaid's Elbow(Required)

4. Medications (Others in System Specific Areas)

Ipecac/Charcoal(Required)

Bronchodilators/Nebulizers(Required)

Fluid Replacement(Required)

Age Specific Competencies

Infant (Birth - 1 year)(Required)

Preschooler (ages 2-5 years)(Required)

Childhood (ages 6-12 years)(Required)

Adolescents (ages 13-21 years)(Required)

Young Adults (ages 22-39 years)(Required)

Adults (ages 40-64 years)(Required)

Older Adults (ages 65-79 years)(Required)

Elderly (ages 80+ years)(Required)

MISCELLANEOUS

Intake and Triage(Required)

National Patient Safety Goals(Required)

AMA procedures(Required)

Disaster Management(Required)

Computerized Charting(Required)

Care of the Patient with

Bites(Required)

Hazardous Materials Exposure(Required)

Victims of Acts of Violence(Required)

My experience is primarily in the following settings

Adults

Year/No of Days

Physician's Office

Year/No of Days

Clinic

Year/No of Days

Urgent Care

Year/No of Days

Emergency Dept - Yrs:

Year/No of Days

Pediatrics

Physician's Office

Year/No of Days

Clinic

Year/No of Days

Urgent Care

Year/No of Days

Emergency Dept - Yrs:

Year/No of Days

CERTIFICATIONS

BLS(Required)

Yes

Date

ACLS(Required)

Yes

Date

PALS(Required)

Yes

Date

Other: Specify

Date

Authorizations

Legal Consent(Required)

I agree to the terms and conditions.

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