Skilled Nursing Checklist One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreName(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 SkillsAdvanced directives(Required) 1 2 3 4 Awareness of HCAHPS(Required) 1 2 3 4 Patient/family teaching(Required) 1 2 3 4 Discharge planning(Required) 1 2 3 4 UR/medicare review(Required) 1 2 3 4 Lift/transfer devices(Required) 1 2 3 4 Specialty beds(Required) 1 2 3 4 Restrictive devices (restraints)(Required) 1 2 3 4 End of life care/palliative care(Required) 1 2 3 4 Automated Medication Dispensing System, Pyxis, Omnicell, or other(Required) 1 2 3 4 National Patient Safety Goals(Required) 1 2 3 4 Accurate patient identification(Required) 1 2 3 4 Effective communication(Required) 1 2 3 4 Awareness of patient rights(Required) 1 2 3 4 Interpretation & communication of lab values(Required) 1 2 3 4 Medication administration(Required) 1 2 3 4 Labeling (medications & specimens)(Required) 1 2 3 4 Medication reconciliation(Required) 1 2 3 4 Anticoagulation therapy(Required) 1 2 3 4 Pain assessment & management(Required) 1 2 3 4 Infection control(Required) 1 2 3 4 Universal precautions(Required) 1 2 3 4 Isolation(Required) 1 2 3 4 Minimize risk for falls(Required) 1 2 3 4 Prevention of pressure ulcers(Required) 1 2 3 4 CardiacAssessment of heart sounds(Required) 1 2 3 4 Identification of arrhythmias (rate/rhythm)(Required) 1 2 3 4 Pacemakers/AID’s(Required) 1 2 3 4 Cardiac arrest/CPR(Required) 1 2 3 4 Hypertension(Required) 1 2 3 4 Pre/post MI(Required) 1 2 3 4 CHF(Required) 1 2 3 4 Post cardiac surgery(Required) 1 2 3 4 Fluid & electrolyte imbalances(Required) 1 2 3 4 Medication AdministrationAnticoagulants(Required) 1 2 3 4 Antiarrhythmics(Required) 1 2 3 4 Beta blockers(Required) 1 2 3 4 Nitroglycerin(Required) 1 2 3 4 Diuretics(Required) 1 2 3 4 RespiratoryAssessment/auscultation of lung sounds(Required) 1 2 3 4 Establishing an airway(Required) 1 2 3 4 Chest PT(Required) 1 2 3 4 Incentive spirometry(Required) 1 2 3 4 Supplemental oxygen (cannula, facemask)(Required) 1 2 3 4 Tracheostomy care(Required) 1 2 3 4 Suctioning (tracheostomy & nasotracheal)(Required) 1 2 3 4 Nebulizer use(Required) 1 2 3 4 Care of Patient with:Pneumonia(Required) 1 2 3 4 Asthma(Required) 1 2 3 4 COPD(Required) 1 2 3 4 Emphysema(Required) 1 2 3 4 Use & Administration of:Bronchodilators(Required) 1 2 3 4 Expectorants(Required) 1 2 3 4 Corticosteroids(Required) 1 2 3 4 NeurologyAssessment of neuro signs(Required) 1 2 3 4 Seizure precautions(Required) 1 2 3 4 Care of Patient with:TBI (Traumatic Brain Injury: history of)(Required) 1 2 3 4 Seizure activity(Required) 1 2 3 4 Spinal cord injury(Required) 1 2 3 4 Stroke (CVA)(Required) 1 2 3 4 Multiple sclerosis(Required) 1 2 3 4 Alzheimer’s disease(Required) 1 2 3 4 Parkinson’s disease(Required) 1 2 3 4 ALS (Amyotrophic Lateral Sclerosis)(Required) 1 2 3 4 ALS (Amyotrophic Lateral Sclerosis)Antiseizure medications(Required) 1 2 3 4 Antiemetics(Required) 1 2 3 4 Laxatives(Required) 1 2 3 4 Enemas(Required) 1 2 3 4 Bowel prep(Required) 1 2 3 4 GastrointestinalNG tube (insertion/removal)(Required) 1 2 3 4 Long term feeding tubes (dobhoff/keofeed)(Required) 1 2 3 4 Gastrostomy tube(Required) 1 2 3 4 Tube feedings(Required) 1 2 3 4 Monitoring input/output(Required) 1 2 3 4 Care of Patient with:Colostomy/ileostomy(Required) 1 2 3 4 GI bleed(Required) 1 2 3 4 Feeding devices/adaptive equipment(Required) 1 2 3 4 Dietary restrictions(Required) 1 2 3 4 GT/PEG feedings(Required) 1 2 3 4 Use & Administration of:Antiemetics(Required) 1 2 3 4 Laxatives(Required) 1 2 3 4 Enemas(Required) 1 2 3 4 Bowel prep(Required) 1 2 3 4 GastrointestinalFoley catheter insertion/removal(Required) 1 2 3 4 GU irrigations(Required) 1 2 3 4 Nephrostomy tube(Required) 1 2 3 4 Suprapubic catheter(Required) 1 2 3 4 Ileo conduit(Required) 1 2 3 4 Use of bladder scan equipment(Required) 1 2 3 4 Care of Patient with:Shunts and fistulas(Required) 1 2 3 4 Straight catheterizations(Required) 1 2 3 4 Incontinence/bladder training(Required) 1 2 3 4 Chronic renal failure/dialysis(Required) 1 2 3 4 Peritoneal dialysis(Required) 1 2 3 4 OrthopedicTotal joint replacement(Required) 1 2 3 4 Arthroscopic surgery(Required) 1 2 3 4 Cast care(Required) 1 2 3 4 Pulse/CMS checks(Required) 1 2 3 4 Suture/staple removal(Required) 1 2 3 4 Prosthesis application(Required) 1 2 3 4 Standard extremity braces(Required) 1 2 3 4 Care of Patient with:Amputation(Required) 1 2 3 4 Stump wrapping(Required) 1 2 3 4 Laminectomy(Required) 1 2 3 4 Assistive devices(Required) 1 2 3 4 CPM machines(Required) 1 2 3 4 IV TherapyStart & maintain Ivs(Required) 1 2 3 4 Blood draw: venous(Required) 1 2 3 4 Central line care (PICC)(Required) 1 2 3 4 Blood draw: central line PICC(Required) 1 2 3 4 Care & management of ports(Required) 1 2 3 4 Infusion pumps(Required) 1 2 3 4 Administration of blood/blood products(Required) 1 2 3 4 SkinWound care/surgical(Required) 1 2 3 4 Wound care/medical(Required) 1 2 3 4 Dressing changes(Required) 1 2 3 4 Skin assessment(Required) 1 2 3 4 Wound vac(Required) 1 2 3 4 Age Specific CompetenciesAge Specific Competencies(Required) 1 2 3 4 Infant (31 days-1 year)(Required) 1 2 3 4 Toddler (2-3 years)(Required) 1 2 3 4 Preschool (ages 4-5 years)(Required) 1 2 3 4 School age (ages 6-12 years)(Required) 1 2 3 4 Adolescents (ages 13-21 years)(Required) 1 2 3 4 Young adult (ages 22-39 years)(Required) 1 2 3 4 Adults (ages 40-64 years)(Required) 1 2 3 4 Older adult (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 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