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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:  
        CHEMO:  
        ONC:  
 

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Cardiovascular

Basic 12 lead EKG interpretation

N/A  

1

2

3

4

Use of Cardiac Monitor

N/A  

1

2

3

4

Assessment of heart sounds (normal vs. abnormal)

N/A  

1

2

3

4

Cardiac arrest/CPR

N/A  

1

2

3

4

Heparin drip (Precautions and maintenance)

N/A  

1

2

3

4

Peripheral Pulses

N/A  

1

2

3

4

Use and administration of

N/A  

1

2

3

4

Anticoagulants

N/A  

1

2

3

4

Antihypertensives

N/A  

1

2

3

4

Digoxin

N/A  

1

2

3

4

Nitroglycerine

N/A  

1

2

3

4

Permanent pacemaker

N/A  

1

2

3

4

Cardiac surgery

N/A  

1

2

3

4

Post acute MI

N/A  

1

2

3

4

Congestive heart failure (CHF)

N/A  

1

2

3

4

Femoral popliteal bypass/Vascular Procedures

N/A  

1

2

3

4

Abdominal aortic aneurysm

N/A  

1

2

3

4

Carotid endarterectomy

N/A  

1

2

3

4

Thrombophlebitis

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

Chest tube (care and maintenance)

N/A  

1

2

3

4

Oxygen Therapy Administration:

N/A  

1

2

3

4

Bag and Mask

N/A  

1

2

3

4

Nasal cannula

N/A  

1

2

3

4

Facemask

N/A  

1

2

3

4

Albuterol (Ventolin)

N/A  

1

2

3

4

Corticosteroids

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

Mechanical ventilator

N/A  

1

2

3

4

COPD

N/A  

1

2

3

4

Emphysema

N/A  

1

2

3

4

Pneumonia

N/A  

1

2

3

4

Pulmonary edema

N/A  

1

2

3

4

 

Neurology

Assessment of neurological status

N/A  

1

2

3

4

Use of Glasgow Coma Scale

N/A  

1

2

3

4

Halo traction

N/A  

1

2

3

4

Assist with Lumbar Puncture

N/A  

1

2

3

4

Post craniotomy

N/A  

1

2

3

4

Shunts (i.e. ventriculoperitoneal)

N/A  

1

2

3

4

CVA

N/A  

1

2

3

4

Seizure activity

N/A  

1

2

3

4

Head injury/trauma

N/A  

1

2

3

4

Spinal cord injury

N/A  

1

2

3

4

Parkinson’s

N/A  

1

2

3

4

Multiple Sclerosis

N/A  

1

2

3

4

DTs/ Impending Delirium Tremens

N/A  

1

2

3

4

 

Orthopedic

Total hip replacement

N/A  

1

2

3

4

Total knee replacement

N/A  

1

2

3

4

CPM (Constant Passive Motion)

N/A  

1

2

3

4

Arthroscopic surgery

N/A  

1

2

3

4

Amputation/stump care

N/A  

1

2

3

4

Ortho trauma

N/A  

1

2

3

4

Skeletal traction

N/A  

1

2

3

4

Spika cast/body cast

N/A  

1

2

3

4

Cast care

N/A  

1

2

3

4

K-wires/Steinman pins

N/A  

1

2

3

4

 

Gastrointestinal

NG tube placement

N/A  

1

2

3

4

Assessment of abdomen

N/A  

1

2

3

4

Administration of tube feeding

N/A  

1

2

3

4

Gastrostomy tube

N/A  

1

2

3

4

Jejunostomy tube (J-tube)

N/A  

1

2

3

4

Colostomy/ileostomy

N/A  

1

2

3

4

GI bleed

N/A  

1

2

3

4

GI surgery

N/A  

1

2

3

4

Hepatitis

N/A  

1

2

3

4

Inflammatory bowel disease

N/A  

1

2

3

4

 

Renal/Genitourinary

Foley catheter insertion

N/A  

1

2

3

4

Care of three-way Foley Catheter

N/A  

1

2

3

4

Bladder irrigations

N/A  

1

2

3

4

Care of supra-pubic catheter

N/A  

1

2

3

4

Nephrectomy

N/A  

1

2

3

4

Renal failure

N/A  

1

2

3

4

Renal transplant

N/A  

1

2

3

4

Peritoneal dialysis

N/A  

1

2

3

4

Fistula/shunt

N/A  

1

2

3

4

T.U.R.P.

N/A  

1

2

3

4

UTI (Urinary Tract Infection)

N/A  

1

2

3

4

 

Gynecology

GYN exam/PAP (assist)

N/A  

1

2

3

4

Hysterectomy

N/A  

1

2

3

4

Ectopic pregnancy

N/A  

1

2

3

4

Mastectomy

N/A  

1

2

3

4

Repair of cystocele/rectocele

N/A  

1

2

3

4

 

Endocrine

Diabetic teaching

N/A  

1

2

3

4

Insulin administration

N/A  

1

2

3

4

Use and Administration of Oral Hypoglycemics

N/A  

1

2

3

4

Blood glucose testing

N/A  

1

2

3

4

 

Oncology

Chemotherapy administration (precautions and side effects)

N/A  

1

2

3

4

Isolation/reverse isolation

N/A  

1

2

3

4

IV hydration

N/A  

1

2

3

4

Nutritional requirements

N/A  

1

2

3

4

Care of bone marrow transplant patient

N/A  

1

2

3

4

Hickman catheter

N/A  

1

2

3

4

Groshong Catheter

N/A  

1

2

3

4

Infusa-port

N/A  

1

2

3

4

Broviac

N/A  

1

2

3

4

Chemotherapy Certification

N/A  

1

2

3

4

 

IV Therapy

Drawing venous blood

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

Start peripheral IV’s

N/A  

1

2

3

4

Maintenance of IV’s

N/A  

1

2

3

4

Administration/mixing IV meds

N/A  

1

2

3

4

Calculate doses

N/A  

1

2

3

4

Calculate rates

N/A  

1

2

3

4

Hanging IV piggybacks

N/A  

1

2

3

4

Insertion of heparin lock

N/A  

1

2

3

4

Maintenance of heparin lock

N/A  

1

2

3

4

Care/maintenance of Central lines

N/A  

1

2

3

4

Nutritional Infusions /Hyperalimentation

N/A  

1

2

3

4

 

Wound and Skin Care

Sterile dressing changes

N/A  

1

2

3

4

Wound irrigations

N/A  

1

2

3

4

Wound culture

N/A  

1

2

3

4

Care of surgical incisions with drains (i.e. JP drain)

N/A  

1

2

3

4

Assessment and care of pressure sores

N/A  

1

2

3

4

Assessment and care of decubitus ulcers

N/A  

1

2

3

4

 

Other Nursing Responsibilities

Physical assessment

N/A  

1

2

3

4

Use of restraints

N/A  

1

2

3

4

Care of the patient with: HIV/AIDS

N/A  

1

2

3

4

Knowledge of Normal Serum Lab Values

N/A  

1

2

3

4

Charge Nurse Responsibilities

N/A  

1

2

3

4