LPN 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 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.
