Skills Checklist – Medical Surgical

Skills Checklist – Medical Surgical

• Name
  
  First
  
  Last
• Phone
• Email
  
• CARE OF PATIENTS WITH*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Abdominal Aortic Aneurysm
  Angina
  Cardiac Arrest
  Cardiogenic Shock
  Carotid Endarterectomy
  Congestive Heart Failure
  Deep Vein Thrombosis
  Post Acute MI (>48 hrs)
  Post Angioplasty
  Fresh Tracheostomy
  Pulmonary Edema
  Pneumonia
  Pneumothorax
  CVA/TIA
  Head Injuries/Intercranial bleeds
  Multiple Sclerosis
  Neuromuscular Disease
  Seizures
  Spinal Cord Injuries
  Renal Failure
  Hepatic Failure
  Hepatitis
  Cholecysitis
  Bowel Obstruction
  GI Bleed
  Inflammatory Bowel Disease
  Paralytic Ileus
  Peritonitis
  TURP/TURBP
  Amputation
  Osteomylelitis
  Total Joint Replacement
  Adrenal Disorders
  Pituitary Disorders
  Burns
  Delirium Tremens
  HIV/AIDS
  Post Thyroidectomy

• CARE OF PATIENTS (POST-OP CARE AFTER) WITH*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  a. GI Surgery
  b. Orthopedic Surgery
  c. Vascular Surgery
  d. GYN Surgery
  Post Mastectomy
  Post Hysterectomy
  Transfusion Reaction

• MEDICATION ADMINISTRATION*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Antibiotics
  Chemotherapeutic Agents
  Digoxin
  Heparin
  Insulin
  Antiarrhythmics
  Antihypertensives
  Anticoagulants
  Oral Hypoglycemics
  Reversal Agents
  Antipsychotics
  Benzodiazepines
  Antidepressants
  TPN Administration
  Inhaled Medications
  Patient Controlled Analgesia (PCA)
  Blood/Blood Product Administration
  Narcotics
  CAD Pump
  Non-opiod Analgesics
  Insulin Pump
  Steroids
  Automated Medication Dispenser (Pyxis)
  Diuretics

• PROCEDURES/SKILLS*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  A-V Fistula Care
  Brace/Splint Application
  Foley/Straight Cath insertion & care
  Central line care
  Chemotherapy
  Chest Tube & Drainage System
  CVP Measurment
  Cardioversion
  Defibrillation
  EKG – obtaining 12 lead
  EKG arrhythmia interpretation
  EKG – lead placement
  Continuous Tube Feeding
  Glascow Coma Scale
  Gastric Lavage, Iced Saline
  Gavage, intermittent Tube Feeding
  Gastric Suction
  Interpretation of Lab Results
  Intestinal Tract Tube Insertion/Care
  Oxygen Therapy Administration
  Pacemaker
  Peritoneal Dialysis
  Specimen Collection
  Suctioning
  Temperature
  Wound/Ostomy Care
  Pressure ulcers

• EQUIPMENT*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Automated Med. Dispensing Systems
  Pneumatic Stockings
  Cardiac/Tele Monitor
  Glucometer
  Hypo/Hyperthermia blanket
  Infusion Pumps
  Specialty Beds
  Ventilator Management/Troubleshooting

• Do you speak any languages other than English?*
  • No

  If yes, enter languages above, separated by commas.

• Age Group Experience*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Newborn (birth – 30 days)
  Infant (30 days – 1 year)
  Toddler (1 – 3 years)
  Preschooler (3 – 5 years)
  School Age (5 – 12 years)
  Adolescents (12 – 18 years)
  Young Adults (18 – 39 years)
  Middle Adults (39-64 years)
  Older Adults (64+ years)

• Confirmation*
  • 
    I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
• Signature
• Date
  
  Date Format: MM slash DD slash YYYY