4/8/24, 10:35 PM AMBULATORY SKILLS CHECKLIST

AMBULATORY
SKILLS CHECKLIST
NAME

LAST 4 OF SSN

DATE

I hereby certify that ALL information I have provided on

this skills checklist and all other documentation, is true
and accurate. I understand and acknowledge that any
misrepresentation or omission may result in
disqualification from employment and/or immediate
termination.

Instructions: This checklist is meant to serve as a general guideline for our client
facilities as to the level of your skills within your nursing specialty. Please use the scale
below to describe your experience/expertise in each area listed below.

Proficiency Scale: 1 = No Experience

2 = Need Training
3 = Able to perform with
supervision
4 = Able to perform
independently

Rating Stars (Click) General Patient Care 1 2 3 4

Admit and Assess Patients

Advance Directives

Collect Appropriate Data

Discharge Teaching

Preoperative Teaching

Patient Prep

Computerized Documentation

Rating Stars (Click) Cardiovascular 1 2 3 4

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Assess Heart Tones

Bedside Tele Monitoring

Interpretation of Coagulation Studies

Perform Pulses/Circulation Checks

Pre/Post Op Care Pacemaker

Rating Stars (Click) Pulmonary 1 2 3 4

Assess Breath Sounds

Apply Oxygen

Interpret ABGs

Thoracentesis

Oximetry

Rating Stars (Click) Neurology 1 2 3 4

Assess Neurological Signs

Epidurals

Selective Nerve Root Blocks

Level of Consciousness

Rating Stars (Click) GI 1 2 3 4

Insertion/Monitoring NG Tubes

Assessment/Patient Care Continued

Flexible Sigmoidoscopy

Hemorrhoid Banding

Liver Biopsy

Paracentesis

Lap Band Surgery

Rating Stars (Click) GU 1 2 3 4

Bladder Biopsy

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Cystoscopy

Urethral Dilation

Nephrostomy

Kidney Biopsy

Suprapubic Catheter

Prostate Biopsy

Rating Stars (Click) Endocrine 1 2 3 4

Care of Diabetic Patient

Diabetic Teaching

Rating Stars (Click) ENT and Mouth 1 2 3 4

Prosthondontics – Restorative Dentistry

Mouth Biopsy

Myringotomy

Maxillofacial Prosthetics

Nose Biopsy

Thyroid Aspirate Biopsy

Fiberoptic Laryngoscopy

Tonsilectomy

Rhinoplasty

Rating Stars (Click) Wounds/Integument 1 2 3 4

Application of Burn Dressings

Application of Dressing

Debridement of Wound

Wound Care

Rating Stars (Click) OB/GYN 1 2 3 4

Electrodesiccation and Curettage (ED&C)

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Nipple Reconstruction

Rating Stars (Click) Musculoskeletal 1 2 3 4

Arthrocentesis

External Hardware and Pin Care

Arthroscopy

Open Reduction and Internal Fixation

Closed Reduction and Internal Fixation

Trigger Point Injections

Rating Stars (Click) Plastics 1 2 3 4

Liposuction

Plastic Surgery

Cosmetic
General Medications/Therapeutic
Rating Stars (Click) 1 2 3 4
Interventions

Administer IM and SQ Meds

Administer Inhalation Medications

Administer PO Medications

Bladder Irrigation and Instillation

Needleless Systems

Chemotherapy

Rating Stars (Click) IV Therapy 1 2 3 4

Infusion Pumps

Peipheral IV Insertion

Syringe Pumps

Vascular Access Devices Care/Maintenance

Administer IV Medications

Rating Stars (Click) Oxygen Administration 1 2 3 4

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Ambu-Bug

Nasal Cannula

Non-ReBreather Mask

Pulse Oximetry

Venti Mask

Face Mask

Rating Stars (Click) Nutritional Therapy 1 2 3 4

Lipids

TPN

Procalamine

Enteral Administration

Rating Stars (Click) Pain Management/Anesthesia 1 2 3 4

Inplantable Narcotic Pump Re ll

Moderate Sedation

Epidural

Spinal

Local

General

Axillary Block

Bier Block

Rating Stars (Click) Blood 1 2 3 4

Blood and Blood Products

Albumin

Rating Stars (Click) General Procedures/Equipment 1 2 3 4

Apply Immobilizers (clavicle, knee, etc.)

Assist with Code Resuscitation

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Assist with Lumbar Puncture

Laser

Dermabrasion

Drain Removal

Incision and Drainage

NGT Insertion

Patch Test

Punch Biopsy

Procedure Set Up

Procedures/Equipment Continued

Remove External Fixators With Pin

Scissor Biopsy

Scrub

Screw-Hardware Removal

Set-up Assist Suturing

Staple Removal

Straight/Foley Cath Female

Straight/Foley Cath Male

Suture Removal

TENS (Transcutaneous Elec. Nerve

Stimulator)

Use of Doppler

Rating Stars (Click) Specimen Collections 1 2 3 4

Venipuncture

Clean Catch Urine

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Sterile Urine Collection

Stool

Sputum

Butter y Stick

Central Line Draw

Rating Stars (Click) Clinical Settings 1 2 3 4

Surgi-Center

Out Patient Clinic

Age Group Experience Continued

Physician O ce

Ambulatory Surgery Clinic

Rating Stars (Click) Joint Commission 1 2 3 4

National Safety Goals

“Do Not Use” Abbreviations and Terms

Rating Stars (Click) Age Specific Competencies 1 2 3 4

Infant (Birth - 1 year)

Preschooler (ages 2-5 years)

Childhood (ages 6-12 years)

Adolescents (ages 13-21 years)

Young Adults (ages 22-39 years)

Adults (ages 40-64 years)

Older Adults (ages 65-79 years)

Elderly (ages 80+ years)

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