RN/LPN - Corrections

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

AGE SPECIFICProficiencyFrequency

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

CLINICAL COMPETENCE OR EXPERIENCE

GENERALProficiencyFrequency

Medical/Surgical Nursing

1

2

3

4

1

2

3

4

Orthopedics

1

2

3

4

1

2

3

4

Obstetrics/Postpartum

1

2

3

4

1

2

3

4

Labor and Delivery

1

2

3

4

1

2

3

4

Nursery

1

2

3

4

1

2

3

4

Pediatrics

1

2

3

4

1

2

3

4

Neonatal Intensive Care Unit

1

2

3

4

1

2

3

4

Telemetry

1

2

3

4

1

2

3

4

Emergency Room

1

2

3

4

1

2

3

4

Operating Room

1

2

3

4

1

2

3

4

Rehabilitation

1

2

3

4

1

2

3

4

Psychiatry/Psychiatric Nursing

1

2

3

4

1

2

3

4

Chemical Dependency(Substance Abuse Treatment)

1

2

3

4

1

2

3

4

Intellectual and Developmental Disabilities

1

2

3

4

1

2

3

4

Post-Anesthesia Care Unit

1

2

3

4

1

2

3

4

Intensive Care Unit/Coronary Care Unit

1

2

3

4

1

2

3

4

Cardiac Intensive Care Unit

1

2

3

4

1

2

3

4

Surgical Intensive Care Unit

1

2

3

4

1

2

3

4

Long-Term Care

1

2

3

4

1

2

3

4

Industrial/Occupational Health

1

2

3

4

1

2

3

4

Correctional Facility Nursing

1

2

3

4

1

2

3

4

Managing suprapubic catheter

1

2

3

4

1

2

3

4

Placing condom catheter

1

2

3

4

1

2

3

4

Collecting urine specimens

1

2

3

4

1

2

3

4

Administering enemas (tap water, Fleet, return flow)

1

2

3

4

1

2

3

4

ENDOCRINE

GENERALProficiencyFrequency

Caring for diabetic patient

1

2

3

4

1

2

3

4

Identifying hypo/hyperglycemia

1

2

3

4

1

2

3

4

Insulin administration

1

2

3

4

1

2

3

4

Checking blood glucose levels

1

2

3

4

1

2

3

4

ADA diets

1

2

3

4

1

2

3

4

Treating hypo/hyperglycemia

1

2

3

4

1

2

3

4

MUSCULOSKELETAL

ASSISTING WITH AMBULATIONProficiencyFrequency

Gait belt

1

2

3

4

1

2

3

4

Walker

1

2

3

4

1

2

3

4

Crutches

1

2

3

4

1

2

3

4

CARING FOR PATIENTS WITHProficiencyFrequency

Braces

1

2

3

4

1

2

3

4

Casts

1

2

3

4

1

2

3

4

Cervical collars

1

2

3

4

1

2

3

4

Slings/Splints

1

2

3

4

1

2

3

4

Bone/Joint disorders

1

2

3

4

1

2

3

4

Amputations

1

2

3

4

1

2

3

4

Stump care

1

2

3

4

1

2

3

4

Prosthetic care

1

2

3

4

1

2

3

4

Caring/Removal of staples and stitches

1

2

3

4

1

2

3

4

Assessing for need of assistive devices

1

2

3

4

1

2

3

4

NUTRITION

GENERALProficiencyFrequency

Caring for patients on fluid restriction

1

2

3

4

1

2

3

4

Caring for patients placed on NPO

1

2

3

4

1

2

3

4

Specialty medical diets

1

2

3

4

1

2

3

4

Counting calories

1

2

3

4

1

2

3

4

Aspiration precautions

1

2

3

4

1

2

3

4

Assisting with nourishments

1

2

3

4

1

2

3

4

VITAL SIGNS AND WEIGHTS

OBTAINING AND RECORDINGProficiencyFrequency

BP including orthostatic

1

2

3

4

1

2

3

4

Pulse/Radial

1

2

3

4

1

2

3

4

Respirations

1

2

3

4

1

2

3

4

Temperature (oral, rectal, axillary, tympanic)

1

2

3

4

1

2

3

4

Weight

1

2

3

4

1

2

3

4

Height

1

2

3

4

1

2

3

4

USE OF ELECTRONIC MONITORING EQUIPMENTProficiencyFrequency

Automatic BP machine (Dynamap)

1

2

3

4

1

2

3

4

Electronic thermometer

1

2

3

4

1

2

3

4

Oximeter

1

2

3

4

1

2

3

4

INFECTION CONTROL

GENERALProficiencyFrequency

Proper use of PPE (gloves, gowns, mask, goggles)

1

2

3

4

1

2

3

4

Isolation/Reverse isolation

1

2

3

4

1

2

3

4

TB precautions

1

2

3

4

1

2

3

4

MRSA precautions

1

2

3

4

1

2

3

4

Body substance isolation

1

2

3

4

1

2

3

4

Hand washing (new CDC guidelines)

1

2

3

4

1

2

3

4

Infectious/Hazardous waste disposal

1

2

3

4

1

2

3

4

Sharps disposal

1

2

3

4

1

2

3

4

SAFETY AND ACTIVITY

GENERALProficiencyFrequency

Use of CPR mask/valve/bag

1

2

3

4

1

2

3

4

Determining patient ID

1

2

3

4

1

2

3

4

Identifying and responding to safety hazards

1

2

3

4

1

2

3

4

Determining the need and when to summon
additional help

1

2

3

4

1

2

3

4

Assessing safety and ADL needs

1

2

3

4

1

2

3

4

Recognizing signs and symptoms of abuse
(substance, physical, emotional)

1

2

3

4

1

2

3

4

Use of proper body mechanics

1

2

3

4

1

2

3

4

Suicide precautions

1

2

3

4

1

2

3

4

Recognizing and responding to psychiatric and
mental health problems

1

2

3

4

1

2

3

4

Use of alarms (bed, patient, unit) and call light

1

2

3

4

1

2

3

4

APPLICATION AND DOCUMENTATION OF RESTRAINTSProficiencyFrequency

Belt

1

2

3

4

1

2

3

4

Seat belt

1

2

3

4

1

2

3

4

Wrist/ankle

1

2

3

4

1

2

3

4

Restraint chairs

1

2

3

4

1

2

3

4

CARE ROUTINES

GENERALProficiencyFrequency

New admissions and transfers

1

2

3

4

1

2

3

4

Health screening

1

2

3

4

1

2

3

4

Medication profile

1

2

3

4

1

2

3

4

Medication administration

1

2

3

4

1

2

3

4

Preparing for and explaining routines to patient

1

2

3

4

1

2

3

4

Starting IVs and IV therapy

1

2

3

4

1

2

3

4

Care of the detox patient

1

2

3

4

1

2

3

4

Knowledge of lab values (chemistry, CBC, drug levels)

1

2

3

4

1

2

3

4

Pain management

1

2

3

4

1

2

3

4

Wound care

1

2

3

4

1

2

3

4

COMMUNICATION AND DOCUMENTATION

GENERALProficiencyFrequency

Communicating with MD/Officers

1

2

3

4

1

2

3

4

Changes in patient condition

1

2

3

4

1

2

3

4

Patient needs, complaints, and concerns

1

2

3

4

1

2

3

4

Unusual incidents

1

2

3

4

1

2

3

4

RECORDING AND REPORTINGProficiencyFrequency

Vital signs

1

2

3

4

1

2

3

4

Patient/Unit activity

1

2

3

4

1

2

3

4

The need for alternative communication mechanism

1

2

3

4

1

2

3

4

UNIT ACTIVITY

GENERALProficiencyFrequency

Identifying unusual incidents on the unit that
require reporting

1

2

3

4

1

2

3

4

Identifying breach of security

1

2

3

4

1

2

3

4

Completing risk management reports as needed

1

2

3

4

1

2

3

4

Charging for patient care items

1

2

3

4

1

2

3

4

Adherence to security protocol

1

2

3

4

1

2

3

4

PATIENTS’ RIGHTS

GENERALProficiencyFrequency

Communicating and maintaining confidentiality
while upholding HIPAA laws

1

2

3

4

1

2

3

4

Providing accurate information to patients in
a timely manner

1

2

3

4

1

2

3

4

Patient’s Right to Care and Right to
Refuse Care

1

2

3

4

1

2

3

4

Years Experience in Clinical Speciality :

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.