Name:
Email:
LAST 4 OF SSN:
This checklist was electronically signed on (Today’s date)
This checklist is designed to guide our client facilities in assessing your proficiency in your nursing specialty. Please use the scale provided to indicate your level of experience and expertise in each of the areas listed below.
Skill Level Indicator:
★ = No Experience
★★ = Requires Training
★★★ = Capable with Supervision
★★★★ = Capable Independently
Couplet Care
Antepartum
Postpartum
Newborn Nursery
LDRP
Vaginal Deliver
Cesarian Section
Anesthesia - General
Anesthesia - Local
Anesthesia - Spinal
Bladder Distention
Breast Milk Collection and Storage
Breast Pump
Breastfeeding - Latch Score
Breastfeeding - Supplemental Feeding
Breastfeeding Support
Contraceptive Education
Epidural/PCA
Homan's Sign
Multiple Births
Parent/Infant Interaction/Attachment
Post Partum Hemorrhage
Pregnancy Induced Hypertension
Tubal Ligation
Amniocentesis
Cardiac Disorders
Diabetes
Hyperemesis
Multiple Gestation
Non-Stress Test
PIH/HELLP
Placenta Previa/Abruptio
Post- Trauma
Pre-Term Labor/Premature Rupture of Membranes
Substance Abuse
FHM Interpretaton and Management
Fetal Assessment
Labor Assessment
Assist with Ultrasound
Antibiotics/Antivirals
Antihypertensives
Antiseizure
Cervical Ripening Agents
Immunizations - Mother
Insulin
Magnesium Sulfate
Methergine
Opioids and Reversal Agents
Pitocin
Terbutaline
Starting Ivs
IV Management
Blood Product Administration
Newborn Assessment
Ballard Scale/Dubowitz
Car Seat Education
Circumcision Care/Teach to Parents
Cord Care/Teach to Parents
Immunizations - Infant
Infant Caretaking Skills
Infant Identification and Security
Metabolic Screen
Phototherapy
Thermoregulation
National Patient Safety Goals/Core Measures
Experience in a "Baby Friendly" Facility
Fall Risk Assessment/Prevention
Pressure Ulcer Risk Assessment/Prevention
Restraints/Use of Least Restrictive Device
Parent/Family Teaching
Age Specific/Population-Based Care
Isolation Precautions
Infection Prevention
Pain Assessment & Management - Adult
Pain Assessment & Management - Neonate
Charge Experience
Interpretation and Communication of Lab Values
Epic
Cerner
Eclipsys
McKesson
Meditech
Other Computerized System
Computerized Physician Order Entry
Bar Coding for Medication Administration
EMR Conversion
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)
BLS
5
CNRN
ACLS
CCRN
Other:
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.
