Ambulatory Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyGeneral Patient CareAdmit and Assess Patients 1 2 3 4 Advance Directives 1 2 3 4 Collect Appropriate Data 1 2 3 4 Discharge Teaching 1 2 3 4 Preoperative Teaching 1 2 3 4 Patient Prep 1 2 3 4 Computerized Documentation 1 2 3 4 CardiovascularAssess Heart Tones 1 2 3 4 Bedside Tele Monitoring 1 2 3 4 Interpretation of Coagulation Studies 1 2 3 4 Perform Pulses/Circulation Checks 1 2 3 4 Pre/Post Op Care Pacemaker 1 2 3 4 PulmonaryAssess Breath Sounds 1 2 3 4 Apply Oxygen 1 2 3 4 Interpret ABGs 1 2 3 4 Thoracentesis 1 2 3 4 Oximetry 1 2 3 4 NeurologyAssess Neurological Signs 1 2 3 4 Epidurals 1 2 3 4 Selective Nerve Root Blocks 1 2 3 4 Level of Consciousness 1 2 3 4 GIInsertion/Monitoring NG Tubes 1 2 3 4 Assessment/Patient Care Continued 1 2 3 4 Flexible Sigmoidoscopy 1 2 3 4 Hemorrhoid Banding 1 2 3 4 Liver Biopsy 1 2 3 4 Paracentesis 1 2 3 4 Lap Band Surgery 1 2 3 4 GUBladder Biopsy 1 2 3 4 Cystoscopy 1 2 3 4 Urethral Dilation 1 2 3 4 Nephrostomy 1 2 3 4 Kidney Biopsy 1 2 3 4 Suprapubic Catheter 1 2 3 4 Prostate Biopsy 1 2 3 4 EndocrineCare of Diabetic Patient 1 2 3 4 Diabetic Teaching 1 2 3 4 ENT and MouthProsthondontics – Restorative Dentistry 1 2 3 4 Mouth Biopsy 1 2 3 4 Myringotomy 1 2 3 4 Maxillofacial Prosthetics 1 2 3 4 Nose Biopsy 1 2 3 4 Thyroid Aspirate Biopsy 1 2 3 4 Fiberoptic Laryngoscopy 1 2 3 4 Tonsilectomy 1 2 3 4 Rhinoplasty 1 2 3 4 Wounds/IntegumentApplication of Burn Dressings 1 2 3 4 Application of Dressing 1 2 3 4 Debridement of Wound 1 2 3 4 Wound Care 1 2 3 4 OB/GYNElectrodesiccation and Curettage (ED&C) 1 2 3 4 Nipple Reconstruction 1 2 3 4 MusculoskeletalArthrocentesis 1 2 3 4 External Hardware and Pin Care 1 2 3 4 Arthroscopy 1 2 3 4 Open Reduction and Internal Fixation 1 2 3 4 Closed Reduction and Internal Fixation 1 2 3 4 Trigger Point Injections 1 2 3 4 PlasticsLiposuction 1 2 3 4 Plastic Surgery 1 2 3 4 Cosmetic 1 2 3 4 General Medications/Therapeutic InterventionsAdminister IM and SQ Meds 1 2 3 4 Administer Inhalation Medications 1 2 3 4 Administer PO Medications 1 2 3 4 Bladder Irrigation and Instillation 1 2 3 4 Needleless Systems 1 2 3 4 Chemotherapy 1 2 3 4 IV TherapyInfusion Pumps 1 2 3 4 Peipheral IV Insertion 1 2 3 4 Syringe Pumps 1 2 3 4 Vascular Access Devices Care/Maintenance 1 2 3 4 Administer IV Medications 1 2 3 4 Oxygen AdministrationAmbu-Bug 1 2 3 4 Nasal Cannula 1 2 3 4 Non-ReBreather Mask 1 2 3 4 Pulse Oximetry 1 2 3 4 Venti Mask 1 2 3 4 Face Mask 1 2 3 4 Nutritional TherapyLipids 1 2 3 4 TPN 1 2 3 4 Procalamine 1 2 3 4 Enteral Administration 1 2 3 4 Pain Management/AnesthesiaInplantable Narcotic Pump Re ll 1 2 3 4 Moderate Sedation 1 2 3 4 Epidural 1 2 3 4 Spinal 1 2 3 4 Local 1 2 3 4 General 1 2 3 4 Axillary Block 1 2 3 4 Bier Block 1 2 3 4 BloodAlbumin 1 2 3 4 Blood and Blood Products 1 2 3 4 General Procedures/EquipmentApply Immobilizers (clavicle, knee, etc.) 1 2 3 4 Assist with Code Resuscitation 1 2 3 4 Assist with Lumbar Puncture 1 2 3 4 Laser 1 2 3 4 Dermabrasion 1 2 3 4 Drain Removal 1 2 3 4 Incision and Drainage 1 2 3 4 NGT Insertion 1 2 3 4 Punch Biopsy 1 2 3 4 Patch Test 1 2 3 4 Procedure Set Up 1 2 3 4 Procedures/Equipment Continued 1 2 3 4 Remove External Fixators With Pin 1 2 3 4 Scissor Biopsy 1 2 3 4 Scrub 1 2 3 4 Screw-Hardware Removal 1 2 3 4 Set-up Assist Suturing 1 2 3 4 Staple Removal 1 2 3 4 Straight/Foley Cath Female 1 2 3 4 Straight/Foley Cath Male 1 2 3 4 Suture Removal 1 2 3 4 TENS (Transcutaneous Elec. Nerve Stimulator) 1 2 3 4 Use of Doppler 1 2 3 4 Specimen CollectionsVenipuncture 1 2 3 4 Clean Catch Urine 1 2 3 4 Sterile Urine Collection 1 2 3 4 Stool 1 2 3 4 Sputum 1 2 3 4 Butter y Stick 1 2 3 4 Central Line Draw 1 2 3 4 Clinical SettingsSurgi-Center 1 2 3 4 Out Patient Clinic 1 2 3 4 Age Group Experience Continued 1 2 3 4 Physician O ce 1 2 3 4 Ambulatory Surgery Clinic 1 2 3 4 Joint CommissionNational Safety Goals 1 2 3 4 “Do Not Use” Abbreviations and Terms 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 Ambulatory Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
