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
Newborn/Neonate (birth to 30 days)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 5 years)
School Age Child (5 years to 12 years)
Adolescents (12 years to 18 years)
Young Adults (18 years to 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)
Acute Care
Skilled/LTAC
Home Health
Workers Compensation
Insurance
Managed Care
Acute Rehab
CMS/Medicare
HEDIS Measures
Core Measures
Medicaid/Medical
DRG
ICD-10 Coding
CPT
RAPS
OBRA
MDS
Benefits Eligibility
Pre-Certification Review
Review for Admission Criteria
Identify Appropriate Level of Care
Develop Care Plans According to Patient Status
Review Status During Stay
Discharge Planning
Physician Advisor
Clinical Documentation Improvement
Needs Assessment/Order DME
Needs Assessment/Home Health
Needs Assessment/Hospice
Needs Assessment/Skilled
Concurrent Review
Retrospective Review
National Patient Safety Goals
Age Specific Care
Population Based Care
Electronic Documentation
Case Management
Mental Health
Healthcare
Client Intake
Crisis Intervention
Social Services
Data Entry
Community Outreach
Nonprofit Organizations
Psychotherapy
Hospitals
Electronic Medical Record (EMR)
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.
