LPN/LVN Skills Checklist

LPN/LVN All the fields are mandatory

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Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency : -	1 = Never Performed	2 = Limited Experience	3 = Comfortable Performing	4 = Proficient
Frequency : -	1 = Never	2 = Sometimes	3 = Often	4 = Always

Medication Administration Proficiency Frequency

Intramuscular Injections

1

2

3

4

1

2

3

4

Z-Track Injections

1

2

3

4

1

2

3

4

Ophthalmic Drops

1

2

3

4

1

2

3

4

Nasal Drops

1

2

3

4

1

2

3

4

Topical Ointments

1

2

3

4

1

2

3

4

Emergency Meds-Crash Cart

1

2

3

4

1

2

3

4

Heparin Lock

1

2

3

4

1

2

3

4

Subcutaneous Injections

1

2

3

4

1

2

3

4

Intradermal

1

2

3

4

1

2

3

4

Inhalers

1

2

3

4

1

2

3

4

Vaginal Suppositories

1

2

3

4

1

2

3

4

Ophthalmic Ointments

1

2

3

4

1

2

3

4

Oral Medications

1

2

3

4

1

2

3

4

Rectal Suppositories

1

2

3

4

1

2

3

4

Starting an IV

1

2

3

4

1

2

3

4

Change IV Tubing

1

2

3

4

1

2

3

4

Discontinuing an IV

1

2

3

4

1

2

3

4

Piggyback Administration

1

2

3

4

1

2

3

4

Plasma

1

2

3

4

1

2

3

4

Packed RBC

1

2

3

4

1

2

3

4

Regulate Flow

1

2

3

4

1

2

3

4

Medication Addition

1

2

3

4

1

2

3

4

Whole Blood Administration

1

2

3

4

1

2

3

4

Serum Albumin

1

2

3

4

1

2

3

4

Platelets

1

2

3

4

1

2

3

4

CVP Line

1

2

3

4

1

2

3

4

Chemo-therapy

1

2

3

4

1

2

3

4

IV Push Drugs

1

2

3

4

1

2

3

4

Hyperalimentation

1

2

3

4

1

2

3

4

Maintain IV Site

1

2

3

4

1

2

3

4

Knowledge of Universal Precautions

1

2

3

4

1

2

3

4

Knowledge of Waste Disposal

1

2

3

4

1

2

3

4

Proper Disposal of Sharps

1

2

3

4

1

2

3

4

Cleaning of Equipment

1

2

3

4

1

2

3

4

Care of the Patient in Reverse Isolation

1

2

3

4

1

2

3

4

Management of Patient in Respiratory Isolation

1

2

3

4

1

2

3

4

Perform Neurological Assessment

1

2

3

4

1

2

3

4

Perform Cardiovascular Assessment

1

2

3

4

1

2

3

4

Perform Genitourinary Assessment

1

2

3

4

1

2

3

4

Perform Respiratory Assessment

1

2

3

4

1

2

3

4

Perform Gastrointestinal Assessment

1

2

3

4

1

2

3

4

Perform Muskuloskelatal Assessment

1

2

3

4

1

2

3

4

Management of the Patient with Drug Interaction/Allergic Reaction

1

2

3

4

1

2

3

4

Management of Patient with Cardio-Pulmonary Arrest

1

2

3

4

1

2

3

4

Lifting and Pulling

1

2

3

4

1

2

3

4

Transfer to Chair

1

2

3

4

1

2

3

4

Transfer Patient to and from Gurney

1

2

3

4

1

2

3

4

Turning and Positioning

1

2

3

4

1

2

3

4

Transfer Patient to Wheelchair

1

2

3

4

1

2

3

4

Transfer Patient to and from Toilet

1

2

3

4

1

2

3

4

Observation of Patient in Restraints

1

2

3

4

1

2

3

4

Documentation

1

2

3

4

1

2

3

4

Application of Soft Limb Restraints

1

2

3

4

1

2

3

4

Application of Posey Restraints

1

2

3

4

1

2

3

4

Knowledgeable of Safety Guidelines for Patient in Restraints

1

2

3

4

1

2

3

4

Application of Leather Restraints

1

2

3

4

1

2

3

4

Hemovac/Davol Suction Pump

1

2

3

4

1

2

3

4

Care of Patient with PCA (Patient Controlled Anesthesia) Pump

1

2

3

4

1

2

3

4

Infusion Devices (Volumetric Pump)

1

2

3

4

1

2

3

4

Venturi Mask

1

2

3

4

1

2

3

4

Management of Trach Collar

1

2

3

4

1

2

3

4

Knowledge of Use of Bed Scale

1

2

3

4

1

2

3

4

Management of Oxygen Mask

1

2

3

4

1

2

3

4

ABG Kits

1

2

3

4

1

2

3

4

Use of Hoyer Lift

1

2

3

4

1

2

3

4

Use of Heat Lamp

1

2

3

4

1

2

3

4

Use of Blood Glucose Monitors

1

2

3

4

1

2

3

4

Use of Wall Suction

1

2

3

4

1

2

3

4

Alternate Pressure Mattress

1

2

3

4

1

2

3

4

Humidifiers

1

2

3

4

1

2

3

4

Use of Corstavac Suction

1

2

3

4

1

2

3

4

Knowledge of Use of Heating Pad

1

2

3

4

1

2

3

4

Assist with/Set-up of Water Seal Suction

1

2

3

4

1

2

3

4

Knowledge of Use of Incentive Spirometer

1

2

3

4

1

2

3

4

Pleurevac/Emerson Suction

1

2

3

4

1

2

3

4

Knowledge of Use of Egg Crate Mattress

1

2

3

4

1

2

3

4

Enteral Pump

1

2

3

4

1

2

3

4

Management of Nasal Cannula

1

2

3

4

1

2

3

4

Use of Ambu-Bag

1

2

3

4

1

2

3

4

Application of TED Hose

1

2

3

4

1

2

3

4

Obtain Urine for Specific Gravity

1

2

3

4

1

2

3

4

Obtain Sputum Specimen

1

2

3

4

1

2

3

4

Instruct Patient/Assist with Clean

1

2

3

4

1

2

3

4

Obtain Stool Hemocult

1

2

3

4

1

2

3

4

Obtain Stool Ova/Parasite

1

2

3

4

1

2

3

4

Obtain Stool Specimen

1

2

3

4

1

2

3

4

Catch/Midstream Urine Specimen

1

2

3

4

1

2

3

4

Obtain Foley Catheter Specimen

1

2

3

4

1

2

3

4

Perform Straight Catheterization

1

2

3

4

1

2

3

4

Collect 24 Hour Urine Specimen

1

2

3

4

1

2

3

4

Obtain Urine Culture

1

2

3

4

1

2

3

4

Perform Personal Hygiene/Oral Care

1

2

3

4

1

2

3

4

Administer Fleets Enema

1

2

3

4

1

2

3

4

Perform Wet to Dry Dressings

1

2

3

4

1

2

3

4

Perform Bladder Irrigation

1

2

3

4

1

2

3

4

Management of Levine Tube

1

2

3

4

1

2

3

4

Management of Jejunostomy Tube

1

2

3

4

1

2

3

4

Management of Chest Tube

1

2

3

4

1

2

3

4

Perform Oral Suctioning

1

2

3

4

1

2

3

4

Perform Wound Irrigation

1

2

3

4

1

2

3

4

Perform Sterile Dressing Changes

1

2

3

4

1

2

3

4

Perform NG Tube Feeding

1

2

3

4

1

2

3

4

Perform Gastrostomy Tube Feeding

1

2

3

4

1

2

3

4

Set-up/Instruct Patient in Sitz Bath

1

2

3

4

1

2

3

4

Administer Tap/Saline Enema

1

2

3

4

1

2

3

4

Administer Soap Suds Enema

1

2

3

4

1

2

3

4

Administer Post-Mortem Care

1

2

3

4

1

2

3

4

Administer Douches

1

2

3

4

1

2

3

4

Perform Catheterization (female & male)

1

2

3

4

1

2

3

4

Administer Oil Retention Enema

1

2

3

4

1

2

3

4

Perform Ostomy Care

1

2

3

4

1

2

3

4

Perform Nasal Suctioning

1

2

3

4

1

2

3

4

Management of Nephrostomy Catheter

1

2

3

4

1

2

3

4

Performing Team Leader Duties

1

2

3

4

1

2

3

4

Giving Tape Report

1

2

3

4

1

2

3

4

Giving Oral Report

1

2

3

4

1

2

3

4

Making Assignments

1

2

3

4

1

2

3

4

Reporting on Assigned Patients

1

2

3

4

1

2

3

4

Making Rounds

1

2

3

4

1

2

3

4

Infant (Birth to 1year)

1

2

3

4

1

2

3

4

Toddler (1-3 years)

1

2

3

4

1

2

3

4

Pre-school (3-6 years)

1

2

3

4

1

2

3

4

School Age (6-12 years)

1

2

3

4

1

2

3

4

Adolescent (12-18 years)

1

2

3

4

1

2

3

4

Young Adult (18-30 years)

1

2

3

4

1

2

3

4

Mature Adult (30-60 years)

1

2

3

4

1

2

3

4

Elderly (>60 years)

1

2

3

4

1

2

3

4

Years Experience in Clinical Specialty :

Most recent facility worked at :

I hereby certify that ALL information I have provided to Clover Health Services, 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.