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Home Health Skills Checklist

Name

Date

Phone

E-mail

I hereby certify that ALL information I have provided to FILL IN THE BLANK 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.

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 Scale: 1 = No Experience, 2 = Need Training, 3 = Able to perform with supervision, 4 = Able to perform independently

CARDIOVASCULAR:

PULMONARY:

Ventilator Management (Specify):

NEUROLOGICAL:

ORTHOPEDICS:

GASTROINTESTINAL:

Feeding Pumps (Specify):

Drainage Devices:

✪ ✪ ✪ ✪ ✪ ✪ ✪ ✪ ✪ ✪ ✪ ✪ ✪ ✪ ✪

RENAL/GENITOURINARY:

ENDOCRINE/METABOLIC:

WOUND/SKIN CARE:

ONCOLOGY:

INFECTIOUS DISEASE:

PHLEBOTOMY/IV THERAPY:

Specify Infusion Pump Type:

PSYCHIATRIC:

WOMEN'S HEALTH/MATERNAL-INFANT CARE:

PEDIATRICS:

Ventilator Type (Specify):

PAIN MANAGEMENT:

PALLIATIVE AND END OF LIFE CARE:

MEDICATIONS:

HOME HEALTH:

Case Load - Pts/Day(specify):

PROFESSIONAL KNOWLEDGE AND SKILLS:

EMR:

EMR Conversion

AGE SPECIFIC COMPETENCIES:

CERTIFICATIONS:

Expiry Date of BLS

Expiry Date of ACLS

Expiry Date of PALS

Expiry Date of IV Certification