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My responses in this checklist represent a true reflection of my experience and comfort level.

Please self-rate your comfort level in performing tasks in connection with the below checklist. Rate your level of comfort for each line item by following the below ranking system. Simply fill in the appropriate option immediately following the rating number.
 
 
 
   
 
  Signature                  :
       
 
  Date                  :
       
          Phone                  :
     
    My Recruiting Professional at Health Source Group is:
    *  
          Level of Comfort/Experience

          N/A=Non-applicable

          1=Inexperienced in this area

          
2=Limited comfort/experience in this area

          
3=Comfortable/experienced in this area

          
4= comfortable/highly experienced in this area



       
Certifications:
(Check all that apply)

        BLS/BCLS/CPR:  
        ACLS:  
 

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Psychiatric

Adolescent

N/A  

1

2

3

4

Adult

N/A  

1

2

3

4

Geriatric

N/A  

1

2

3

4

Suicidal risk assessment

N/A  

1

2

3

4

Administration of psychotropic medications

N/A  

1

2

3

4

Charge nurse experience

N/A  

1

2

3

4

Contact precautions

N/A  

1

2

3

4

Discharge patient AMA

N/A  

1

2

3

4

DSM IV diagnosis

N/A  

1

2

3

4

Emergency custody order

N/A  

1

2

3

4

Group therapy leader

N/A  

1

2

3

4

Management of assaultive behavior

N/A  

1

2

3

4

Management of alcohol withdrawal symptoms

N/A  

1

2

3

4

Management of Narcotic withdrawal symptoms

N/A  

1

2

3

4

Management of violent patient

N/A  

1

2

3

4

Patient rights

N/A  

1

2

3

4

Psychiatric emergency response team

N/A  

1

2

3

4

Rapid tranquilization

N/A  

1

2

3

4

Restraints, application and assessment of

N/A  

1

2

3

4

Telephonic crisis intervention

N/A  

1

2

3

4

Therapeutic communication skills

N/A  

1

2

3

4

Eating disorder

N/A  

1

2

3

4

Hallucinations

N/A  

1

2

3

4

Lithium toxicity

N/A  

1

2

3

4

Manic-depression

N/A  

1

2

3

4

OD

N/A  

1

2

3

4

Substance abuse

N/A  

1

2

3

4

Schizophrenia

N/A  

1

2

3

4

Seclusion

N/A  

1

2

3

4

Suicidal behavior

N/A  

1

2

3

4

 

Cardiovascular

Basic 12 lead EKG interpretation

N/A  

1

2

3

4

Defibrillation/cardioversion

N/A  

1

2

3

4

Care of the patient with CHF (congestive heart failure)

N/A  

1

2

3

4

Care of the patient with permanent pacemaker

N/A  

1

2

3

4

 

Pulmonary

Assessment of breath sounds

N/A  

1

2

3

4

Chest physiotherapy

N/A  

1

2

3

4

Oral suctioning

N/A  

1

2

3

4

Nasotracheal suctioning

N/A  

1

2

3

4

Pulse oximeter use

N/A  

1

2

3

4

Interpretation of ABG’s panic values

N/A  

1

2

3

4

Chest tube

N/A  

1

2

3

4

COPD

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

Face mask

N/A  

1

2

3

4

Nasal cannula

N/A  

1

2

3

4

Portable O2 tank

N/A  

1

2

3

4

 

Neurology

Assessment of neurological status

N/A  

1

2

3

4

Assist with Lumbar Puncture

N/A  

1

2

3

4

CVA

N/A  

1

2

3

4

DT’s

N/A  

1

2

3

4

Seizure activity

N/A  

1

2

3

4

 

Gastrointestinal

Assessment of abdomen

N/A  

1

2

3

4

Administration of tube feeding

N/A  

1

2

3

4

Colostomy/ileostomy

N/A  

1

2

3

4

Hepatitis

N/A  

1

2

3

4

NG tube

N/A  

1

2

3

4

 

IV Therapy

Start and maintenance of peripheral IV’s

N/A  

1

2

3

4

Start and maintenance of saline/heparin lock

N/A  

1

2

3

4

Administration of IV fluids

N/A  

1

2

3

4

Administration of blood and blood products (precautions, recognizing transfusion reactions and taking appropriate actions)

N/A  

1

2

3

4

Administration and mixing of IV meds

N/A  

1

2

3

4

Hang IV piggybacks

N/A  

1

2

3

4

Use of infusion pumps

N/A  

1

2

3

4

Knowledge of access and maintenance of central lines and catheters

N/A  

1

2

3

4

 

Additional nursing responsibilities

Cast care

N/A  

1

2

3

4

Insertion and care of Foley catheter

N/A  

1

2

3

4

Knowledge of Normal Serum Lab Values

N/A  

1

2

3

4

Knowledge of isolation techniques and procedures

N/A  

1

2

3

4

Universal precautions

N/A  

1

2

3

4

Blood glucose testing

N/A  

1

2

3

4

Insulin administration

N/A  

1

2

3

4

Sterile dressing changes

N/A  

1

2

3

4

Assessment and care of pressure sores

N/A  

1

2

3

4

Decubitus ulcers

N/A  

1

2

3

4

Care of the pt. With AIDS

N/A  

1

2

3

4