Nurse Practitioner Skills Checklist

Area worked

Emergency

1

2

3

4

1

2

3

4

Urgent care

1

2

3

4

1

2

3

4

Private practice

1

2

3

4

1

2

3

4

HMO

1

2

3

4

1

2

3

4

MD Office

1

2

3

4

1

2

3

4

Schools

1

2

3

4

1

2

3

4

Health department

1

2

3

4

1

2

3

4

Ambulatory clinic

1

2

3

4

1

2

3

4

Rural health clinic

1

2

3

4

1

2

3

4

Psychiatric facility

1

2

3

4

1

2

3

4

Mobile medical unit

1

2

3

4

1

2

3

4

Corporate worksite

1

2

3

4

1

2

3

4

Health department

1

2

3

4

1

2

3

4

Occupational health

1

2

3

4

1

2

3

4

Nursing home/Long term care facility

1

2

3

4

1

2

3

4

Women's health clinic

1

2

3

4

1

2

3

4

Government health agency

1

2

3

4

1

2

3

4

Correctional facility

1

2

3

4

1

2

3

4

Cardiology

1

2

3

4

1

2

3

4

Other (list)

1

2

3

4

1

2

3

4

Specialty

ASHD (arteriosclerotic heart disease)

1

2

3

4

1

2

3

4

Dyslipidemia

1

2

3

4

1

2

3

4

Osteomyelitis

1

2

3

4

1

2

3

4

PVD (Peripheral vascular disease)

1

2

3

4

1

2

3

4

HTN (hypertension)

1

2

3

4

1

2

3

4

Peripheral neuropathy

1

2

3

4

1

2

3

4

Diabetes

1

2

3

4

1

2

3

4

Orthopaedic

1

2

3

4

1

2

3

4

Emergency department

1

2

3

4

1

2

3

4

Other (list)

1

2

3

4

1

2

3

4

Experience with

IPPB machine use

1

2

3

4

1

2

3

4

Diabetes

1

2

3

4

1

2

3

4

Cather care

1

2

3

4

1

2

3

4

Gastrostomy care

1

2

3

4

1

2

3

4

Incontinence care-bowel

1

2

3

4

1

2

3

4

Dermal ulcers

1

2

3

4

1

2

3

4

Enemas/Suppositories/Fecal

1

2

3

4

1

2

3

4

Injections

1

2

3

4

1

2

3

4

Bedridden residents

1

2

3

4

1

2

3

4

Pap smears

1

2

3

4

1

2

3

4

Audiometry

1

2

3

4

1

2

3

4

Tympanometry

1

2

3

4

1

2

3

4

Splinting of extremities

1

2

3

4

1

2

3

4

Interpret ABG (blood gases)

1

2

3

4

1

2

3

4

Local infiltration

1

2

3

4

1

2

3

4

Fluorescein staining of eyes

1

2

3

4

1

2

3

4

Excisions

1

2

3

4

1

2

3

4

Intubations

1

2

3

4

1

2

3

4

Chronic disease condition

1

2

3

4

1

2

3

4

Differential diagnosis

1

2

3

4

1

2

3

4

Oxygen administration

1

2

3

4

1

2

3

4

Liquid oxygen

1

2

3

4

1

2

3

4

Contractures

1

2

3

4

1

2

3

4

Staph infections

1

2

3

4

1

2

3

4

Tracheotomies

1

2

3

4

1

2

3

4

Wond care

1

2

3

4

1

2

3

4

Visual acuity

1

2

3

4

1

2

3

4

Interpreting 12 lead EKG's

1

2

3

4

1

2

3

4

Single layer wound closure

1

2

3

4

1

2

3

4

Radiographic interpretation (initial)

1

2

3

4

1

2

3

4

Incision and drainage

1

2

3

4

1

2

3

4

Comprehensive physical assessment

1

2

3

4

1

2

3

4

Acute disease condition

1

2

3

4

1

2

3

4

Naso-gastric tubes

1

2

3

4

1

2

3

4

Order, may perform, and interpret screening and
diagnostic test

1

2

3

4

1

2

3

4

Explanation to patient/family

1

2

3

4

1

2

3

4

Documentation

1

2

3

4

1

2

3

4

Venipuncture

1

2

3

4

1

2

3

4

Sputum Collection

1

2

3

4

1

2

3

4

Ultrasounds

1

2

3

4

1

2

3

4

Informed consent

1

2

3

4

1

2

3

4

Hemoglobinmeter

1

2

3

4

1

2

3

4

Urine Collection

1

2

3

4

1

2

3

4

Pregnancy test kits

1

2

3

4

1

2

3

4

Collaboration

Family, Support system, community resources

1

2

3

4

1

2

3

4

Consulting with Physicians

1

2

3

4

1

2

3

4

Consulting with Pharmacists

1

2

3

4

1

2

3

4

Consulting with Occupational Therapist

1

2

3

4

1

2

3

4

Others (list)

1

2

3

4

1

2

3

4

Consulting with Dietician and Diet Aide

1

2

3

4

1

2

3

4

Consulting with Speech Therapist

1

2

3

4

1

2

3

4

Referral to Pastoral services

1

2

3

4

1

2

3

4

Drug Therapy

Prescription

1

2

3

4

1

2

3

4

Over the counter (OTC)

1

2

3

4

1

2

3

4

Knowledge of pharmacology

1

2

3

4

1

2

3

4

Knowledge of pharmacokinetics

1

2

3

4

1

2

3

4

Knowledge of drug interactions

1

2

3

4

1

2

3

4

Knowledge of side effects

1

2

3

4

1

2

3

4

Herbal drugs

1

2

3

4

1

2

3

4

Anaphylaxis reaction

1

2

3

4

1

2

3

4

Allergic reactions

1

2

3

4

1

2

3

4

Dispensing Medications

Management of controlled substances

1

2

3

4

1

2

3

4

Monitoring drug therapy

1

2

3

4

1

2

3

4

Dispensing Medications

Monitoring drug therapy

1

2

3

4

1

2

3

4

Management of controlled substances

1

2

3

4

1

2

3

4

Non-Pharmacologic Interventions

Medical nutrition therapy

1

2

3

4

1

2

3

4

Cessation of substance abuse (alcoho, tobacoo)

1

2

3

4

1

2

3

4

Obesity management

1

2

3

4

1

2

3

4

Other (list)

1

2

3

4

1

2

3

4

Exercise

1

2

3

4

1

2

3

4

Mental health issues (stress management,
depression)

1

2

3

4

1

2

3

4

Miscellaneous

Public health and health promotion

1

2

3

4

1

2

3

4

Research

1

2

3

4

1

2

3

4

Quality assurance

1

2

3

4

1

2

3

4

Leadership and teaching skills

1

2

3

4

1

2

3

4

Legal and ethical issues

1

2

3

4

1

2

3

4

Confidentiality

1

2

3

4

1

2

3

4

Cultural awareness

1

2

3

4

1

2

3

4

Working within scope of practice

1

2

3

4

1

2

3

4

Discharge planning / collaboration

1

2

3

4

1

2

3

4

Self-evaluation to improve patient care

1

2

3

4

1

2

3

4

Continuing education

1

2

3

4

1

2

3

4

Infant (Birth to 1 year)

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.

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