NAME:       ID #:       DATE:       This Skills Checklist is for use by nurses with more than one year experience in their discipline and specialty. Please be accurate with your assessment. DESCRIPTION 1 2 3 4 Admitting a Patient Discharging a Patient Ambulating a Patient Hand washing HIPPA (Privacy) Patients Bill of Rights Universal Precautions Charting: Graphic Flow sheet Computer Progress Notes Blood Pressure Choking CPR Intake & Output (I&O) Oral Hygiene Oral Suctioning Pulse Respirations Temperature: Apical Axillary Centigrade Fahrenheit Rectal Weights: Bed Scale Chair Scale Stand up Scale Bed Making: Unoccupied Occupied Post-op Range of Motion: Active Passive 1 | Page DIRECTIONS: Please indicate your level of experience by placing a check (√) in the box. Experience level: 1 NO EXPERIENCE 2 MINIMAL EXPERIENCE-requires

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MODERATELY EXPERIENCED-requires initial review, then performs independently VERY EXPERIENCED- proficient 1 2 3 4

DESCRIPTION Bathing: Complete Bed Bath Bed Shampoo Partial Bed Bath Shaving a patient Showering a patient Showering w/ chair Tub Bath Hoyer lift Gait Belt Transfer: Traction Bed to Chair Bed to Commode Bed to Stretcher Bed to WC Psychiatric: Care of a Combative Patient Care of a Suicidal Patient Care of a Confused Patient Behavior Modification Preventing Patient Harm Preventing Personal harm Obtaining Assistant to Prevent Crisis Care of the Patient with: Cast Care Back Care Colostomy Care Decubiti-Care Gastrostomy Care Perineal Care Tracheostomy Care

Other: Enema (Fleets) Name: DESCRIPTION 1 2 3 4 Enema (Other) Rectal Tubes Hypothermia Blanket O2 Administration Isolation Techniques Use of Restraints K-Pads Types of Facilities that you have worked in: Adult Day Care Ambulatory Clinic Home Care Hospital Long Term Care Facility Mental Health Pediatric Day Care Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care. A. Newborn/Neonatal (birth – 30 days) Y B. Infant (30 days – 1 year) N C. Toddler (1 – 3 years) N D. Preschool (3 – 5 years) N E. School Age Children (5 – 12 years) N F. Adolescent (12 – 18 years) N G. Young Adults (18 – 39 years) N H. Middles Adults (40 – 64 years) N I. Older Adults (64 + years) N N Y Y Y Y Y Y Y Y

ID #:       I HAVE CURRENT CERTIFICATIONS FOR: TYPE EXPIRATION (MM/DD/YY) Health Care Worker       CPR Health Care Worker       BLS NRP       ACLS       Basic First Aid       Medication       Certification Other             Other             The information I have provided in this knowledge and skills checklist it true and accurate to the best of my knowledge.       Signature


ID #:       This skills checklist has been reviewed and approved by Nicole Bloxham, RN.       Signature       Date


ID #:      
Please return to: Northwest Company, PA ATTN: Records Dept. Nurse Staffing

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Fax: (866) 352-4338 Email:

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