LPN Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlySkillsActivities of daily living 1 2 3 4 Admission of patient 1 2 3 4 Administration of medication 1 2 3 4 Ambulation 1 2 3 4 Application of heat and cold 1 2 3 4 Aseptic Technique 1 2 3 4 Assist with medical examination 1 2 3 4 Bathing: Sitz, tub, bed, shower 1 2 3 4 Bandaging 1 2 3 4 Binders 1 2 3 4 Body Alignment 1 2 3 4 Body Systems Review (Head to Toe data collection) 1 2 3 4 Cast care 1 2 3 4 Catheterization / Foley catheter care 1 2 3 4 Charting 1 2 3 4 Colostomy Care and irrigation 1 2 3 4 CPR 1 2 3 4 Crutch walking 1 2 3 4 Decubitus Care 1 2 3 4 Diabetic tests and preparation forms 1 2 3 4 Diabetic blood glucose testing 1 2 3 4 Discharge patients 1 2 3 4 Dosage computation 1 2 3 4 Draping 1 2 3 4 Dressing (sterile) 1 2 3 4 Ear drops 1 2 3 4 Elimination needs 1 2 3 4 Enemas, cleansing, retention, Harris flush 1 2 3 4 Restraints 1 2 3 4 Infection Control: Standard Universal Precautions 1 2 3 4 Infection Control: Reverse Isolation 1 2 3 4 Infection Control: TB/ Airborne Precautions 1 2 3 4 Infections Control: MRSA/ VRE Precautions 1 2 3 4 Isolation procedure for specimen collection 1 2 3 4 IVs: Monitor rate and infusion site 1 2 3 4 Medications: Oral, IM, SQ 1 2 3 4 Mouth care 1 2 3 4 Nail Care 1 2 3 4 Neurological Check 1 2 3 4 Nutritional Check 1 2 3 4 Observations: Response to treatments/ meds 1 2 3 4 Observations: Signs of significant body system changes 1 2 3 4 Observations: Signs of shock 1 2 3 4 Observations: Signs of pain 1 2 3 4 Observes safety procedures 1 2 3 4 O2 administration 1 2 3 4 Pain assessment 1 2 3 4 Patient care plans (revise and update) 1 2 3 4 Patient safety standards/ precautions 1 2 3 4 Positioning patient 1 2 3 4 Postural drainage 1 2 3 4 Pre-op and post-op care 1 2 3 4 Provide comfort, safety and privacy 1 2 3 4 Pulse oxymetry 1 2 3 4 Range of motion 1 2 3 4 Report observations/ changes 1 2 3 4 Hand hygiene 1 2 3 4 Skin care 1 2 3 4 Specimen collection: routine urine 1 2 3 4 Specimen collection: clean catch 1 2 3 4 Specimen collection: 12 & 24 hour specimen 1 2 3 4 Specimen collection: stool 1 2 3 4 Specimen collection: culture 1 2 3 4 Specimen collection: sputum 1 2 3 4 Specimen collection: from foley catheter 1 2 3 4 Suppositories 1 2 3 4 Suction-oral 1 2 3 4 Surgical Preps 1 2 3 4 Computerized charting 1 2 3 4 Trach care/suctioning 1 2 3 4 Telephone manners 1 2 3 4 Topical Medication Application 1 2 3 4 Traction 1 2 3 4 Transfer/ transport patients: wheelchair 1 2 3 4 Transfer/ transport patients: gurney 1 2 3 4 Transfer/ transport patients: to chair 1 2 3 4 Urine test for glucose/ acetone 1 2 3 4 Vital Signs 1 2 3 4 Weight: Bed scales and standing scales 1 2 3 4 IV therapy certified 1 2 3 4 Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this LPN Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.Your NameYour NameYour NameYour Name
