Ambulatory 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 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.Your NameYour NameYour NameYour Name
