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.
| Patient Rights | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Communicates and obtains information while respecting the rights and privacy and confidentiality of information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) |
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| Involves the patient and family and respects their role in determining the nature of care to be provided, including Advance Directives. |
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| Complies with nursing staff responsibility included in the hospital policy related to Organ Donation. |
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| Meets patient and families needs regarding communication, including interpreter services |
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| Provides accurate information to patient and families in a timely manner. |
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| Vital Signs and Weights | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| BP, including Orthostatic |
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| Pulse, Radia |
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| Temperature, Oral |
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| Temperature, Rectal |
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| Temperature, Axillary |
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| Temperature, Tympanic |
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| Respirations |
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| Weight, Pounds and Kilograms |
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| Recognizing Cardiac Arrest |
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| Activating Code Team |
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| Bringing Emergency Equipment to Room |
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| Providing Appropriate Code Support |
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| Automatic BP machine (Dynamap) |
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| Electronic Thermometer |
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| Applying Oximeter |
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| Standing |
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| Chair |
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| Bed |
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| Report Abnormal Findings |
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| Bowel Function |
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| Bladder Function |
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| Tap Water |
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| Fleets |
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| Return Flow |
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| Vital Signs and Weights | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Placing and Removing Bed Pan |
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| Clamping Catheter |
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| Emptying Foley Bag |
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| Placing Condom Catheter |
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| Emptying and Replacing Ostomy Bag (Established Ostomy) |
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| Nutrition | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Estimating Intake |
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| Setting up for Meals |
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| Feeding Patients |
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| Aspiration Precautions |
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| Nourishments |
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| Counting Calories |
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| Fluid Restriction |
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| NPO |
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| Specimens | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Collecting Stool |
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| Collecting Sputum |
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| Labeling Specimens and Preparing for Transport |
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| Clean Catch |
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| 24 Hour |
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| Hygiene /Skin | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Risk Factorsfor Skin Breakdown |
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| Observing Pressure Points for Redness or Breakdown |
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| Bathing (Shower /Tub /Arjo) |
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| Oral Care, Including Patients who are NPO,Comatose, Patients with |
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| Pen Care |
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| Foot Care for Patients with Impaired Circulation or Sensation |
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| Incontinence Care |
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| Shaving and Precautions |
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| Reducing Pressure and Friction |
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| Special Beds/Mattresses |
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| Heels and Elbow Protection |
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| Foot Cradles |
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| Use of Shower Chair |
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| Use of Bath/Shower Boat |
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| Infection Control | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Reverse Isolation |
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| Body Substance isolation |
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| TB Precautions |
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| MRSA Precautions |
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| Hand Washing |
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| Infectious/Hazardous Waste Disposal |
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| Supply/Equipment Disposal |
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| Use of Disposable Therrnomete |
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| Use of CPR Mask/Bag |
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| Gloves |
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| Gown |
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| Mask / Goggles |
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| Safety and Activity | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Determining Patient ID |
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| Identifying Safety Hazards |
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| Determining Need for Additional Help |
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| Assessing Safety and ADL Needs |
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| Assessing Safety and ADL Needs |
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| Recognizing Abuse: Substance, Physical, Emotional, etc |
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| MaintainingClean, Orderly Work Area |
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| Disposing of Sharps |
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| Handling Hazardous Materials |
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| Proper Body Mechanics |
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| ROM Exercises |
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| Transferring to Bed,WC, Commode, etc |
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| Turning and Positioning |
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| Patient Safety Module |
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| Reporting Broken Equipment |
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| Responding to Safety Hazards |
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| Use of HoyerLift (Dextra /Maxi) |
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| Bed Operation |
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| Use of Wheel Locks |
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| Use of Alarms: Bed, Patient, Unit |
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| Use of CaIl Light |
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| Documenting Use of Restraints |
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| Use of Transfer Belt |
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| Use of Gait Belt for Ambulation |
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| Use of Seizure Pads |
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| Belt Including Seat Belt |
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| Wrist/Ankle |
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| Vest |
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| Care Routines | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Inventory andDispositionof Belongings, Useof Checklist |
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| Room Orientation, Call Bell |
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| Transferring into Bed |
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| Call Bell |
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| Assist with Turns |
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| ROM Exercises |
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| Replacing Mask or Nasal Caunula if Needed |
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| Notifying Nurse of Problems |
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| Basic Comfort Measures |
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| Early Bath |
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| Preparing Belongings |
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| Preparingfor and Explaining Routinesto Patient |
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| Post Mortem Care |
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| Use ofIncentive Spirometer |
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| Antiembolic Stockings |
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| Sequential Stockings |
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| Communication | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Using Appropriate Abbreviations |
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| Identifying UnusuaI Patient Incidents that Require Reporting |
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| Reinforcing RN Teaching With Patient |
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| Selecting and Using Forms Appropriately |
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| Using Alternate Communication Tools /Devices |
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| Changes in Patient Condition |
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| Patient Needs, Complaints and Concerns |
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| Unusual Incidents |
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| Vital Signs |
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| Bathing /Hygiene |
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| Turning and Repositioning |
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| Ambulation and Activity |
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| Diet intake, Calorie Count |
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| Bowel Movements |
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| Shift Volumes and Totals |
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| Marking and /or Measuring Amount of Urine, Gastric Fluid, NG Drainage, Emesis, Diarrhea |
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| Unit Activity | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Identifying Unusual Incidents on the Unit that Require Reporting |
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| Locating and Using Appropriate Reference Materials: Hospital, Patient Care and |
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| Charging for Patient Care Items |
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| Completing Risk Management Reports as Needed |
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| Obtaining Needed Supplies and Equipment |
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| Reporting and Following up on Faulty Equipment and Supplies |
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| Using Telephone System |
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| Age Specific Competencies | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Infant (Birth - 1 year) |
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| Preschooler (ages 2-5 years) |
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| Childhood (ages 6-12 years) |
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| Adolescents (ages 13-21 years) |
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| Young Adults (ages 22-39 years) |
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| Adults (ages 40-64 years) |
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| Older Adults (ages 65-79 years) |
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| Elderly (ages 80+ years) |
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