PHYSICAL THERAPY KNOWLEDGE & SKILLS CHECKLIST

NAME:       DIRECTIONS: Please indicate your level of experience by

ID #:       placing a check (√) in the box. Experience level:
DATE:       1 NO EXPERIENCE
2 MINIMAL EXPERIENCE-requires supervision/assistance
This Skills Checklist is for use by nurses with more than 3 MODERATELY EXPERIENCED-requires initial review,
one year experience in their discipline and specialty. then performs independently
Please be accurate with your assessment. 4 VERY EXPERIENCED- proficient

DESCRIPTION 1 2 3 4 DESCRIPTION 1 2 3 4
PATIENT GROUPS 5. Hand Injury
1. Geriatric 6. TMJ Dysfunction
2. Adult 7. Arthritis Programs
3. Adolescent 8. Mobilization Techniques
4. Pediatric 9. Gait Training
5. Infants 10. Neck Injury
WORK SETTINGS PEDIATRICS
1. General Acute Care 1. Early Intervention
2. Rehabilitation Hospital 2. NICU Treatment
3. Sports Medicine Clinic 3. Neurodevelopment Testing
4. Children’s Hospital 4. Neurodevelopment Treating
5. School System 5. Developmental Disability Sequencing
6. Home Health Care Test
7. Skilled Nursing Facility 6. Orthotics
8. Outpatient 7. Equipment Assessment:
9. MR/DD a. Adaptive
10. Assisted Living Facility b. Activities of daily living
DIAGNOSTIC 8. Mental Retardation
1. CVA/Stroke 9. Cerebral Palsy
2. Neurologic 10. Learning Disabled
3. Orthopedic 11. Spina Bifida
4. Head Trauma MODALITIES
5. Burns 1. Hot/Cold Packs
6. Head Injuries 2. Muscle Stimulation
7. Sports Injuries 3. Biofeedback
8. Amputees 4. TENS
9. Spinal Cord Injury 5. Ultrasound
10. Cardiac Rehab 6. Diathermy
11. Pulmonary Rehab 7. Cryotherapy
ORTHOPEDICS 8. Fluidotherapy
1. Total Hip/Total Knee 9. Paraffin Bath
2. Hip Fractures 10. Massage
3. Total Joint Replacement 11. Traction:
4. Back Syndrome a. Cervical

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 PHYSICAL THERAPY KNOWLEDGE & SKILLS CHECKLIST
DESCRIPTION 1 2 3 4
NAME:       5. Inservice Education
ID #:       6. Work Capacity Evaluation
DATE:       7. Geriatrics
8. Functional Capacity Evaluation
DESCRIPTION 1 2 3 4 COMPUTERIZED CHARTING
MODALITIES (CONT) 1. Cerner
b. Lumbar 2. Eclipsys
12. Wound Dressing 3. Epic
13. Hydrotherapy 4. McKesson
a. Hubbard Tank 5. Meditech
b. Therapeutic Pool 6. Other:
c. Whirlpool
14. Myofacial Release Techniques
NEUROLOGIC
1. Stroke Rehabilitation
2. Head Trauma
3. Coma Management
4. Spinal Cord Injury
PROSTHETICS/ORTHOTICS
1. AK Prosthetics
2. BK Prosthetics
3. UE Prosthetics
4. Orthoplast
5. Resting Splints
6. AFO/PLS
7. Static Splinting
8. Dynamic Splinting
9. Serial/ Inhibitory Casting
SPORTS MEDICINE
1. Cybex
2. Biodex
3. Orthotron/Kinetron
4. Lido
5. Nautilus/Eagle
6. Taping/Strapping
7. Strength/ Endurance Training
8. Bracing Joint Immobilization
OTHER
1. Wheelchair:
a. Seating
b. Ordering
2. Burn Management
3. Cardiac Rehabilitation
4. Chest Physiotherapy
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 PHYSICAL THERAPY KNOWLEDGE & SKILLS CHECKLIST
MY EXPERIENCE IS PRIMARILY IN:
Name:      
NEUROLOGY       years
Please check the boxes below for each age group for PULMONARY       years
which you have expertise in providing age-appropriate SURGICAL       years
nursing care. MEDICAL       years
CARDIAC CARE       years
A. Newborn/Neonatal (birth – 30 days) TELEMETRY       years
B. Infant (30 days – 1 year)
C. Toddler (1 – 3 years) I HAVE CURRENT CERTIFICATIONS FOR:
D. Preschool (3 – 5 years)
E. School Age Children (5 – 12 years) TYPE COURSE DATE (MM/DD/YY)
F. Adolescent (12 – 18 years) ARRHYTHMIA      
G. Young Adults (18 – 39 years) CRITICAL CARE      
H. Middle Adults (40 – 64 years) ACLS      
I. Older Adults (64 + years) BLS      
TNCC      
EXPERIENCE WITH AGE GROUPS: NRP      
1. Able to assess age appropriate behavior, motor skills PALS      
and physiological norms. NALS      
Other            
A B C D E F G H I Other            
Other            
Other            
2. Able to adapt care according to normal growth and
development. The information I have provided in this knowledge and
skills checklist it true and accurate to the best of my
A B C D E F G H I knowledge.

           
3. Able to communicate and instruct patient according to Signature (Written/Electronic) Date
their age, maturity and comprehension ability. ID #:      

A B C D E F G H I This skills checklist has been reviewed and approved by

Nicole Bloxham, RN.

4. Able to provide a safe environment according to the            

specific needs of various age groups. Signature (Written/Electronic) Date
ID #:      
A B C D E F G H I
Please return to: Northwest Nurse Staffing Company, PA
ATTN: Records Dept.
Fax: (866) 352-4338

Email: records@nns-ic.com

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