RN Ambulatory Care Skills Checklist

RN Ambulatory Care 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

Pre-op Proficiency Frequency

Admit and Assess Patients

1

2

3

4

1

2

3

4

Advance Directives

1

2

3

4

1

2

3

4

Collect Appropriate Data

1

2

3

4

1

2

3

4

Discharge Teaching

1

2

3

4

1

2

3

4

Preoperative Teaching

1

2

3

4

1

2

3

4

Patient Prep

1

2

3

4

1

2

3

4

Computerized Documentation

1

2

3

4

1

2

3

4

IV Placement and Management

1

2

3

4

1

2

3

4

Clean Catch Urine

1

2

3

4

1

2

3

4

Sterile Urine Collection

1

2

3

4

1

2

3

4

Stool

1

2

3

4

1

2

3

4

Sputum

1

2

3

4

1

2

3

4

Butterfly Stick

1

2

3

4

1

2

3

4

Central Line Draw

1

2

3

4

1

2

3

4

Administer IM and SQ Medications

1

2

3

4

1

2

3

4

Administer Inhalation Medications

1

2

3

4

1

2

3

4

Administer PO Medications

1

2

3

4

1

2

3

4

Bladder Irrigation and Instillation

1

2

3

4

1

2

3

4

Needleless Systems

1

2

3

4

1

2

3

4

Chemotherapy

1

2

3

4

1

2

3

4

Ambu-Bag

1

2

3

4

1

2

3

4

Nasal Cannula

1

2

3

4

1

2

3

4

Non-Rebreather Mask

1

2

3

4

1

2

3

4

Pulse Oximetry

1

2

3

4

1

2

3

4

Venti Mask

1

2

3

4

1

2

3

4

Face Mask

1

2

3

4

1

2

3

4

Bedside Tele Monitoring

1

2

3

4

1

2

3

4

Moderate Sedation

1

2

3

4

1

2

3

4

Assist with Code Resuscitation

1

2

3

4

1

2

3

4

Apply Immobilizers (clavicle, knee, etc.)

1

2

3

4

1

2

3

4

Assist with Code Resuscitation

1

2

3

4

1

2

3

4

Assist with Lumbar Puncture

1

2

3

4

1

2

3

4

Laser Procedures

1

2

3

4

1

2

3

4

Dermabrasion

1

2

3

4

1

2

3

4

Drain Removal

1

2

3

4

1

2

3

4

NGT Insertion

1

2

3

4

1

2

3

4

Patch Test

1

2

3

4

1

2

3

4

Punch Biopsy

1

2

3

4

1

2

3

4

Procedure Setup

1

2

3

4

1

2

3

4

Remove External Fixators with Pin

1

2

3

4

1

2

3

4

Scissor Biopsy

1

2

3

4

1

2

3

4

Scrub

1

2

3

4

1

2

3

4

Screw-Hardware Removal

1

2

3

4

1

2

3

4

Setup Assist Suturing

1

2

3

4

1

2

3

4

Staple Removal

1

2

3

4

1

2

3

4

Straight/Foley Catheter (Female and Male)

1

2

3

4

1

2

3

4

Suture Removal

1

2

3

4

1

2

3

4

TENS (Transcutaneous Electrical Nerve Stimulator)

1

2

3

4

1

2

3

4

Use of Doppler

1

2

3

4

1

2

3

4

Incision and Drainage

1

2

3

4

1

2

3

4

Implantable Narcotic Pump Refill

1

2

3

4

1

2

3

4

Epidural

1

2

3

4

1

2

3

4

Spinal

1

2

3

4

1

2

3

4

Local Anesthesia

1

2

3

4

1

2

3

4

General Anesthesia

1

2

3

4

1

2

3

4

Axillary Block

1

2

3

4

1

2

3

4

Bier Block

1

2

3

4

1

2

3

4

Assess Heart Tones

1

2

3

4

1

2

3

4

Bedside Tele Monitoring

1

2

3

4

1

2

3

4

Obtain a 12 Lead EKG

1

2

3

4

1

2

3

4

Interpretation of Laboratory Studies

1

2

3

4

1

2

3

4

Perform Pulses/Circulation Checks

1

2

3

4

1

2

3

4

Auscultate Heart Sounds

1

2

3

4

1

2

3

4

Pre/Post Op Care Pacemaker

1

2

3

4

1

2

3

4

Pacemaker Implantation

1

2

3

4

1

2

3

4

Cardiac Catheterization

1

2

3

4

1

2

3

4

Ablation for Atrial Fibrillation

1

2

3

4

1

2

3

4

Cardioversion

1

2

3

4

1

2

3

4

Implantable Loop Recorder

1

2

3

4

1

2

3

4

Electrophysical Study

1

2

3

4

1

2

3

4

Assess Neurological Baseline Status

1

2

3

4

1

2

3

4

Epidurals

1

2

3

4

1

2

3

4

Selective Nerve Root Blocks

1

2

3

4

1

2

3

4

Level of Consciousness

1

2

3

4

1

2

3

4

Carpal Tunnel Release

1

2

3

4

1

2

3

4

Cervical or Lumbar Discectomy

1

2

3

4

1

2

3

4

Spinal Cord Stimulatory Implantation

1

2

3

4

1

2

3

4

Vagal Nerve Stimulator (VNS) Placement

1

2

3

4

1

2

3

4

Ulnar Nerve Transposition

1

2

3

4

1

2

3

4

Peripheral Nerve Decompression

1

2

3

4

1

2

3

4

Shunt Revision

1

2

3

4

1

2

3

4

Deep Brain Stimulation (DBS) Programming Adjustments

1

2

3

4

1

2

3

4

Assess Breath Sounds

1

2

3

4

1

2

3

4

Apply Oxygen

1

2

3

4

1

2

3

4

Interpret ABGs

1

2

3

4

1

2

3

4

Bronchoscopy

1

2

3

4

1

2

3

4

Thoracentesis

1

2

3

4

1

2

3

4

Oximetry

1

2

3

4

1

2

3

4

Lung Biopsy

1

2

3

4

1

2

3

4

Endobronchial Ultrasound

1

2

3

4

1

2

3

4

Pleurodesis

1

2

3

4

1

2

3

4

Lung Volume Reduction Surgery (LVRS)

1

2

3

4

1

2

3

4

Insertion/Monitoring NG Tubes

1

2

3

4

1

2

3

4

Flexible Sigmoidoscopy

1

2

3

4

1

2

3

4

Endoscopic Retrograde Cholangiopancreatography (ERCP)

1

2

3

4

1

2

3

4

Colonoscopy

1

2

3

4

1

2

3

4

Hemorrhoid Banding

1

2

3

4

1

2

3

4

Upper Endoscopy (EGD)

1

2

3

4

1

2

3

4

Hernia Repair

1

2

3

4

1

2

3

4

Polypectomy

1

2

3

4

1

2

3

4

Pyloroplasty

1

2

3

4

1

2

3

4

Liver Biopsy

1

2

3

4

1

2

3

4

Paracentesis

1

2

3

4

1

2

3

4

Lap Band Surgery

1

2

3

4

1

2

3

4

Catheter Care

1

2

3

4

1

2

3

4

Catheter Insertion

1

2

3

4

1

2

3

4

Bladder Biopsy

1

2

3

4

1

2

3

4

Cystoscopy

1

2

3

4

1

2

3

4

Urethral Dilation

1

2

3

4

1

2

3

4

Nephrostomy

1

2

3

4

1

2

3

4

Kidney Biopsy

1

2

3

4

1

2

3

4

Suprapubic Catheter

1

2

3

4

1

2

3

4

Prostate Biopsy

1

2

3

4

1

2

3

4

Vasectomy

1

2

3

4

1

2

3

4

Ureteroscopy

1

2

3

4

1

2

3

4

Hydrocelectomy

1

2

3

4

1

2

3

4

Penile Implant Surgery

1

2

3

4

1

2

3

4

Circumcision (Adult)

1

2

3

4

1

2

3

4

Transurethral Resection of Prostate (TURP)

1

2

3

4

1

2

3

4

Prosthodontics – Restorative Dentistry

1

2

3

4

1

2

3

4

Mouth Biopsy

1

2

3

4

1

2

3

4

Myringotomy

1

2

3

4

1

2

3

4

Maxillofacial Prosthetics

1

2

3

4

1

2

3

4

Nose Biopsy

1

2

3

4

1

2

3

4

Thyroid Aspirate Biopsy

1

2

3

4

1

2

3

4

Fiberoptic Laryngoscopy

1

2

3

4

1

2

3

4

Tonsillectomy

1

2

3

4

1

2

3

4

Sinus Surgery

1

2

3

4

1

2

3

4

Myringotomy with Tube Placement

1

2

3

4

1

2

3

4

Septoplasty

1

2

3

4

1

2

3

4

Balloon Sinuplasty

1

2

3

4

1

2

3

4

Tympanoplasty

1

2

3

4

1

2

3

4

Rhinoplasty

1

2

3

4

1

2

3

4

Hysterectomy

1

2

3

4

1

2

3

4

Dilation and Curettage

1

2

3

4

1

2

3

4

Endometrial Ablation

1

2

3

4

1

2

3

4

Laparoscopic Tubal Ligation

1

2

3

4

1

2

3

4

LEEP (Loop Electrosurgical Excision Procedure)

1

2

3

4

1

2

3

4

Ovarian Cyst Removal

1

2

3

4

1

2

3

4

Liposuction

1

2

3

4

1

2

3

4

Rhinoplasty

1

2

3

4

1

2

3

4

Breast Augmentation or Reduction

1

2

3

4

1

2

3

4

Blepharoplasty (Eyelid Surgery)

1

2

3

4

1

2

3

4

Otoplasty

1

2

3

4

1

2

3

4

Facelift (Mini Facelift)

1

2

3

4

1

2

3

4

Hernia Repair

1

2

3

4

1

2

3

4

Circumcision

1

2

3

4

1

2

3

4

Ear Tube Surgery

1

2

3

4

1

2

3

4

Orchiopexy

1

2

3

4

1

2

3

4

Gastrostomy Tube Placement

1

2

3

4

1

2

3

4

Hypospadias

1

2

3

4

1

2

3

4

Infant (Birth – 1 year)

1

2

3

4

1

2

3

4

Preschooler (ages 2-5 years)

1

2

3

4

1

2

3

4

Childhood (ages 6-12 years)

1

2

3

4

1

2

3

4

Adolescents (ages 13-21 years)

1

2

3

4

1

2

3

4

Young Adults (ages 22-39 years)

1

2

3

4

1

2

3

4

Adults (ages 40-64 years)

1

2

3

4

1

2

3

4

Older Adults (ages 65-79 years)

1

2

3

4

1

2

3

4

Elderly (ages 80+ 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.