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.
Areas Worked | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Emergency |
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Urgent Care |
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Private Practice |
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HMO |
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MD Office |
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Schools |
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Health Department |
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Ambulatory Clinic |
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Rural Health Clinic |
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Psychiatric Facility |
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Correctional Facility |
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Mobile Medical Unit |
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Corporate Worksite |
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Occupational Health |
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Rehabilitation |
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Nursing Home/ Long-term Care Facility |
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Women's Health Clinic |
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Government Health Agency |
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Hospice/Palliative Care |
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Experience With | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Diabetes |
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Contractures |
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Bedridden residents |
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Splinting of extremities |
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Local infiltration |
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Comprehensive physical assessment |
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Acute disease condition |
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Differential diagnosis |
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Order, may perform, & interpret screening & diagnostic test |
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Central line management |
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Disorders – Emergencies | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Anaphylaxis |
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Cardiac arrest |
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Seizures |
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Minor head injuries |
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Animal bites |
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Ingestions and poisonings |
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Overdose of sedative, hypnotics, opiates |
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Snake bites |
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Minor burns |
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Shock |
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Open wounds |
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Collaboration | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Family, support system, community resources |
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Consulting with Physicians |
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Consulting with Pharmacists |
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Consulting with Speech Therapist |
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Consulting with Dietician and Diet Aide |
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Consulting with Occupational Therapist |
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Referral to Pastoral Services |
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Respiratory | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Croup |
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Influenza |
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Tracheobronchitis |
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Bronchitis |
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COPD (chronic obstructive pulmonary disease) |
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Asthma |
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URI (upper respiratory infection) |
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Obstructive Sleep Apnea |
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Viral |
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Bacterial |
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Bacterial |
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Nonbacteria |
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Oxygen administration |
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Liquid oxygen |
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IPPB machine use |
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Tracheotomies |
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Interpret ABG (blood gases) |
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Intubations |
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Sputum Collection |
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Cardiovascular System | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Congestive heart failure |
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Chronic obstructive pulmonary disease |
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Stasis ulcer of lower extremities |
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Angina |
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Pericarditis |
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Coronary artery disease |
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Functional murmurs |
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Congenital heart disease |
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Hypertension |
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ASHD (arteriosclerotic heart disease) |
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Dyslipidemia |
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PVD (peripheral vascular disease) |
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Peripheral neuropathy |
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Interpreting 12 lead EKG’s |
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OB/GYN | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Candida vaginitis |
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Dysmenorrhea |
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Abnormal pap smear findings |
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Pap smears |
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Trichomonal vaginitis |
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Atrophic vaginitis |
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Fibrocystic breast disease |
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Menopause |
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Intrapartum medications |
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Bartholin's cyst/abscess |
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Preparation for childbirth |
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Pregnancy - diagnosis and referral |
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Pain relief in active phase of labor |
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Medications in the third stage |
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Dysfunctional uterine bleeding |
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Medications in the postpartum phase |
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Rh blood factor |
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Mastitis |
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Birth control methods |
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Prenatal care |
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Fetal well-being |
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Nausea and vomiting with pregnancy |
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Pap smears |
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Pregnancy test kits |
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GI System | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Constipation |
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Diarrhea (simple) |
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Acute gastroenteritis |
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Cholecystitis |
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Pyloric stenosis |
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Colic |
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Appendicitis |
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Naso-gastric tubes |
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Gastrostomy Care |
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Skin | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Warts |
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Basal cell carcinoma |
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Scabies |
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Impetigo |
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Diaper dermatitis |
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Acne |
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Folliculitis |
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Furuncles |
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Carbuncles |
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Herpes Simplex |
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Herpes Zoster |
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Malignant melanoma |
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Pityriasis Rosea |
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Contact dermatitis |
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Tinea corporis |
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Tinea pedis |
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Staph infections |
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Wound care |
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Single layer wound closure |
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Incision and drainage |
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Excisions |
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Ears, Nose and Throat | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Epistaxis |
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Otitis externa |
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Serous otitis media |
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Acute purulent otitis media |
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Allergic rhinitis |
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Pharyngitis |
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Oral candidiasis |
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Eye | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Conjunctivitis |
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Strabismus |
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Chalazion |
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Stye |
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Visual acuity |
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Fluorescein staining of eyes |
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Audiometry |
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Tympanometry |
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Musculoskeletal | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Osteoporosis |
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Osteomyelitis |
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Rheumatoid arthritis |
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Juvenile diabetes |
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Gout |
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Minor sprains and strains |
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Osteoarthritis |
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Carpal tunnel syndrome |
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Scoliosis |
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Tendonitis |
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Bursitis |
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Muscular dystrophy |
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Parasitic Infections | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Pinworms |
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Ascariasis |
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Pediculosis |
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Genitourinary System | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Syphilis |
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Chlamydia |
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Herpes |
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Cystitis |
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Pyelonephritis |
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Urinary tract infection |
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Benign prostatic hypertrophy |
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Vulvovaginitis |
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Hypospadias |
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Hydrocele |
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Gonococcal infections |
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Prostatitis |
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Catheter Care |
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Incontinence care-bowel |
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Dermal ulcers |
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Enemas/ Suppositories/ Fecal |
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Urine collection |
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Nervous System | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Vasovagal syncope |
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Migraine headaches |
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Multiple sclerosis |
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Headaches |
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Head injury |
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Tension |
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Anxiety |
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Parkinson’s |
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Alzheimer’s |
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Bell’s Palsy |
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TIA (transient ischemic attacks) |
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Trigeminal neuralgia |
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Endocrine | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Type I diabetes mellitus |
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Type II diabetes mellitus |
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Graves disease |
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Addison's disease |
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Juvenile diabetes |
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Hypoglycemia |
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Hypothyroidism |
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Hematological | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Folic acid deficiency anemia |
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Aplastic anemia |
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Iron deficiency |
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Sickle cell anemia |
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Pernicious anemia |
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Hemoglobinmeter |
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Psychosocial | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Depression |
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Suicide |
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Obesity |
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Grief |
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Anxiety |
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Anorexia |
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Bulimia |
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Drug Therapy | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Prescription |
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Over the counter (OTC) |
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Herbal drugs |
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Knowledge of pharmacology |
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Knowledge of pharmacokinetics |
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Knowledge of drug interactions |
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Knowledge of side effects |
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Allergic reactions |
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Anaphylaxis reaction |
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TPN/Lipid Management |
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Management/Titration of IV Therapies |
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IV/PO Antibiotic Therapy and understanding of cultures |
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Dispensing Medication | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Monitoring drug therapy |
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Management of controlled substances |
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Injections |
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Non-Pharmacologic Interventions | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Medical nutrition therapy |
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Exercise |
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Cessation of substance abuse (alcohol, tobacco) |
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Mental health issues (stress management, depression) |
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Obesity management |
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Tube Feeding Management |
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Miscellaneous | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Public health and health promotion |
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Research |
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Quality assurance |
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Leadership and teaching skills |
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Legal and ethical issues |
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Confidentiality |
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Cultural awareness |
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Self evaluation to improve patient care |
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Continuing education |
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Working within scope of practice |
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Discharge planning / collaboration |
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Suturing |
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Cell biopsy |
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Starting IV |
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Casting and splinting |
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Radiographic interpretation (initial) |
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Informed consent |
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Explanation to patient/family |
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Documentation |
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Venipuncture |
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Ultrasounds |
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Programs | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
OSHA (Occupational Safety and Health Administration) |
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Medicare and Medicaid |
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CLIA waiver (Clinical Laboratory Improvement Amendments) |
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TJC (The Joint Commission) |
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HEDIS (Health Plan Employer Data and Information Set) |
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DQIP (Diabetes Quality Improvement Program) |
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HIPAA (Health Insurance Portability & Accountability Act) |
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HCAHPS |
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Age Specific Competencies | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Newborn/neonate (birth-30 days) |
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Infant (31 days-1 year) |
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Toddler (ages 2-3 years) |
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Preschool (ages 4-5 years) |
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School age (ages 6-12 years) |
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Adolescents (ages 13-21 years) |
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Young adult (ages 22-39 years) |
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Adults (ages 40-64 years) |
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Older adult (ages 65-79 years) |
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Elderly (ages 80+ years) |
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