AMBULATORY SKILLS CHECKLIST One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) This field is hidden when viewing the formDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyGeneral Patient CareAdmit and Assess Patients(Required) 1 2 3 4 Advance Directives(Required) 1 2 3 4 Collect Appropriate Data(Required) 1 2 3 4 Discharge Teaching(Required) 1 2 3 4 Preoperative Teaching(Required) 1 2 3 4 Patient Prep(Required) 1 2 3 4 Computerized Documentation(Required) 1 2 3 4 CardiovascularAssess Heart Tones(Required) 1 2 3 4 Bedside Tele Monitoring(Required) 1 2 3 4 Interpretation of Coagulation Studies(Required) 1 2 3 4 Perform Pulses/Circulation Checks(Required) 1 2 3 4 Pre/Post Op Care Pacemaker(Required) 1 2 3 4 PulmonaryAssess Breath Sounds(Required) 1 2 3 4 Apply Oxygen(Required) 1 2 3 4 Interpret ABGs(Required) 1 2 3 4 Thoracentesis(Required) 1 2 3 4 Oximetry(Required) 1 2 3 4 NeurologyAssess Neurological Signs(Required) 1 2 3 4 Epidurals(Required) 1 2 3 4 Selective Nerve Root Blocks(Required) 1 2 3 4 Level of Consciousness(Required) 1 2 3 4 GIInsertion/Monitoring NG Tubes(Required) 1 2 3 4 Assessment/Patient Care Continued(Required) 1 2 3 4 Flexible Sigmoidoscopy(Required) 1 2 3 4 Hemorrhoid Banding(Required) 1 2 3 4 Liver Biopsy(Required) 1 2 3 4 Paracentesis(Required) 1 2 3 4 Lap Band Surgery(Required) 1 2 3 4 GUBladder Biopsy(Required) 1 2 3 4 Cystoscopy(Required) 1 2 3 4 Urethral Dilation(Required) 1 2 3 4 Nephrostomy(Required) 1 2 3 4 Kidney Biopsy(Required) 1 2 3 4 Suprapubic Catheter(Required) 1 2 3 4 Prostate Biopsy(Required) 1 2 3 4 EndocrineCare of Diabetic Patient(Required) 1 2 3 4 Diabetic Teaching(Required) 1 2 3 4 ENT and MouthProsthondontics – Restorative Dentistry(Required) 1 2 3 4 Mouth Biopsy(Required) 1 2 3 4 Myringotomy(Required) 1 2 3 4 Maxillofacial Prosthetics(Required) 1 2 3 4 Nose Biopsy(Required) 1 2 3 4 Thyroid Aspirate Biopsy(Required) 1 2 3 4 Fiberoptic Laryngoscopy(Required) 1 2 3 4 Tonsilectomy(Required) 1 2 3 4 Rhinoplasty(Required) 1 2 3 4 Wounds/IntegumentApplication of Burn Dressings(Required) 1 2 3 4 Application of Dressing(Required) 1 2 3 4 Debridement of Wound(Required) 1 2 3 4 Wound Care(Required) 1 2 3 4 OB/GYNElectrodesiccation and Curettage (ED&C)(Required) 1 2 3 4 Nipple Reconstruction(Required) 1 2 3 4 MusculoskeletalArthrocentesis(Required) 1 2 3 4 External Hardware and Pin Care(Required) 1 2 3 4 Arthroscopy(Required) 1 2 3 4 Open Reduction and Internal Fixation(Required) 1 2 3 4 Closed Reduction and Internal Fixation(Required) 1 2 3 4 Trigger Point Injections(Required) 1 2 3 4 PlasticsLiposuction(Required) 1 2 3 4 Plastic Surgery(Required) 1 2 3 4 Cosmetic(Required) 1 2 3 4 General Medications/Therapeutic InterventionsAdminister IM and SQ Meds(Required) 1 2 3 4 Administer Inhalation Medications(Required) 1 2 3 4 Administer PO Medications(Required) 1 2 3 4 Bladder Irrigation and Instillation(Required) 1 2 3 4 Needleless Systems(Required) 1 2 3 4 Chemotherapy(Required) 1 2 3 4 IV TherapyInfusion Pumps(Required) 1 2 3 4 Peipheral IV Insertion(Required) 1 2 3 4 Syringe Pumps(Required) 1 2 3 4 Vascular Access Devices Care/Maintenance(Required) 1 2 3 4 Administer IV Medications(Required) 1 2 3 4 Oxygen AdministrationAmbu-Bug(Required) 1 2 3 4 Nasal Cannula(Required) 1 2 3 4 Non-ReBreather Mask(Required) 1 2 3 4 Pulse Oximetry(Required) 1 2 3 4 Venti Mask(Required) 1 2 3 4 Face Mask(Required) 1 2 3 4 Nutritional TherapyLipids(Required) 1 2 3 4 TPN(Required) 1 2 3 4 Procalamine(Required) 1 2 3 4 Enteral Administration(Required) 1 2 3 4 Pain Management/AnesthesiaInplantable Narcotic Pump Re ll(Required) 1 2 3 4 Moderate Sedation(Required) 1 2 3 4 Epidural(Required) 1 2 3 4 Spinal(Required) 1 2 3 4 Local(Required) 1 2 3 4 General(Required) 1 2 3 4 Axillary Block(Required) 1 2 3 4 Bier Block(Required) 1 2 3 4 BloodBlood and Blood Products(Required) 1 2 3 4 Albumin(Required) 1 2 3 4 General Procedures/EquipmentApply Immobilizers (clavicle, knee, etc.)(Required) 1 2 3 4 Assist with Code Resuscitation(Required) 1 2 3 4 Assist with Lumbar Puncture(Required) 1 2 3 4 Laser(Required) 1 2 3 4 Dermabrasion(Required) 1 2 3 4 Drain Removal(Required) 1 2 3 4 Incision and Drainage(Required) 1 2 3 4 NGT Insertion(Required) 1 2 3 4 Patch Test(Required) 1 2 3 4 Punch Biopsy(Required) 1 2 3 4 Procedure Set Up(Required) 1 2 3 4 Procedures/Equipment Continued(Required) 1 2 3 4 Remove External Fixators With Pin(Required) 1 2 3 4 Scissor Biopsy(Required) 1 2 3 4 Scrub(Required) 1 2 3 4 Screw-Hardware Removal(Required) 1 2 3 4 Set-up Assist Suturing(Required) 1 2 3 4 Staple Removal(Required) 1 2 3 4 Straight/Foley Cath Female(Required) 1 2 3 4 Straight/Foley Cath Male(Required) 1 2 3 4 Suture Removal(Required) 1 2 3 4 TENS (Transcutaneous Elec. Nerve Stimulator)(Required) 1 2 3 4 Use of Doppler(Required) 1 2 3 4 Specimen CollectionsVenipuncture(Required) 1 2 3 4 Clean Catch Urine(Required) 1 2 3 4 Sterile Urine Collection(Required) 1 2 3 4 Stool(Required) 1 2 3 4 Sputum(Required) 1 2 3 4 Butter y Stick(Required) 1 2 3 4 Central Line Draw(Required) 1 2 3 4 Clinical SettingsSurgi-Center(Required) 1 2 3 4 Out Patient Clinic(Required) 1 2 3 4 Age Group Experience Continued(Required) 1 2 3 4 Physician O ce(Required) 1 2 3 4 Ambulatory Surgery Clinic(Required) 1 2 3 4 Joint CommissionNational Safety Goals(Required) 1 2 3 4 “Do Not Use” Abbreviations and Terms(Required) 1 2 3 4 Age Specific CompetenciesInfant (Birth - 1 year)(Required) 1 2 3 4 Preschooler (ages 2-5 years)(Required) 1 2 3 4 Childhood (ages 6-12 years)(Required) 1 2 3 4 Adolescents (ages 13-21 years)(Required) 1 2 3 4 Young Adults (ages 22-39 years)(Required) 1 2 3 4 Adults (ages 40-64 years)(Required) 1 2 3 4 Older Adults (ages 65-79 years)(Required) 1 2 3 4 Elderly (ages 80+ years)(Required) 1 2 3 4 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. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
