Medical/Surgical Skills Checklist Personal InformationName(Required) First Middle Last Date MM slash DD slash YYYY Key To Competency Levels0 – No Experience 1 – Minimal experience, need review and supervision, have performed at least once 2 – Comfortable performing with resource available 3 – Competent to perform independently and safely 4 – Expert, able to act as resource to othersNuerologyCommunicates and obtains information while respecting the rights and privacy and confidentiality of information. 0 1 2 3 4 Complies with nursing staff responsibility include in the hospital policy related to Organ Donation. 0 1 2 3 4 Involves the patient and family and respects their role in determining the nature of care to be provided, including Advanced Directives. 0 1 2 3 4 Meets patient and families needs regarding communication, including interpreter services. 0 1 2 3 4 Provides accurate information to patient and families in a timely manner. 0 1 2 3 4 Patients RightsNeuro Assessment/Neuro Vitals 0 1 2 3 4 Seizure Precautions 0 1 2 3 4 Stryker Frame 0 1 2 3 4 Crutchfield Tongs 0 1 2 3 4 Halo Traction 0 1 2 3 4 Immobilization Techniques 0 1 2 3 4 Care of Patient with: Spinal Cord Injury 0 1 2 3 4 Care of Patient with: Pre/Post Neurological Surgery 0 1 2 3 4 Care of Patient with: CNS Infections 0 1 2 3 4 Care of Patient with: Degenerative Diseases of the Nervous System 0 1 2 3 4 Care of Patient with: Drug Overdose 0 1 2 3 4 Care of Patient with: Acute Head injury 0 1 2 3 4 Care of Patient with: Cerebral Aneurysm 0 1 2 3 4 Care of Patient with: Acute/Chronic C.V.A/T.I.A. 0 1 2 3 4 Care of Patient with: Rehabilitation of the Neuro patient 0 1 2 3 4 Managing patient with epidural catheter 0 1 2 3 4 Managing patient with spinal precautions 0 1 2 3 4 CardiovascularCardio pulmonary arrests 0 1 2 3 4 Running code 99 0 1 2 3 4 Caring for 48+ hour post-op Open Heart patient 0 1 2 3 4 Caring for a pacemaker patient 0 1 2 3 4 Pre/post-op angioplasty 0 1 2 3 4 Post-op vascular surgery patients (i.e. aneurysms) 0 1 2 3 4 Angina (acute and chronic) 0 1 2 3 4 Ability to interpret cardiac rhythms 0 1 2 3 4 Care of patient with: Valvular disease 0 1 2 3 4 Care of patient with: Central lines 0 1 2 3 4 Assessing and treating orthostatic BP 0 1 2 3 4 Assessing abnormal heart tones 0 1 2 3 4 Medication and AdministrationKnowledge of Indications, Actions, Contraindications, Side Effects, Methods of Administration, Calculation of Dose, Rate of Infusion, caring for and monitoring patient receiving the following:Acetaminophen 0 1 2 3 4 Acetylsalicylic Acid 0 1 2 3 4 Antibiotics 0 1 2 3 4 Beta blockers 0 1 2 3 4 Calcium Channel Blockers 0 1 2 3 4 Cimetidine 0 1 2 3 4 Codeine 0 1 2 3 4 Dexamethasone 0 1 2 3 4 Diazepam 0 1 2 3 4 Digoxin 0 1 2 3 4 Duramorph 0 1 2 3 4 Furosemide 0 1 2 3 4 Heparin 0 1 2 3 4 Insulin 0 1 2 3 4 Lorazepam 0 1 2 3 4 Morphine 0 1 2 3 4 Naloxone 0 1 2 3 4 Nitroglycerine 0 1 2 3 4 Phenytoin 0 1 2 3 4 Potassium Chloride 0 1 2 3 4 Theophylline 0 1 2 3 4 Verapamil 0 1 2 3 4 Warfarin 0 1 2 3 4 Inhalers 0 1 2 3 4 Oral Medications 0 1 2 3 4 Suppositories: Vaginal 0 1 2 3 4 Suppositories: Rectal 0 1 2 3 4 Ordering Meds 0 1 2 3 4 PulmonaryAssessment of breath sounds 0 1 2 3 4 Assist with set-up maintenance of chest tubes 0 1 2 3 4 Administer oxygen (nasal canula, mask, endotracheal) 0 1 2 3 4 Oxygen saturation monitor 0 1 2 3 4 Use of chest drainage systems 0 1 2 3 4 Care of patient with: Pulmonary emboli 0 1 2 3 4 Care of patient with: Tracheostomy 0 1 2 3 4 Care of patient with: Pre/post thoracic surgery 0 1 2 3 4 Care of patient with: Asthma 0 1 2 3 4 Care of patient with: COPD 0 1 2 3 4 Care of patient with: CHF 0 1 2 3 4 Care of patient with: Tuberculosis 0 1 2 3 4 Nasal Tracheal Suctioning 0 1 2 3 4 Changing Tracheostomy 0 1 2 3 4 Instructing patient in use of incent. spirometer 0 1 2 3 4 GastrointestinalAssessment of bowel sounds 0 1 2 3 4 Identification of abnormalities 0 1 2 3 4 Stool tests 0 1 2 3 4 Insert/Maintain Feeding tubes/NG tubes 0 1 2 3 4 Administering Tube Feedings 0 1 2 3 4 Checking Tube Feeding Residuals 0 1 2 3 4 Inserting/maintaining intermittent & continuous suction NG tubes 0 1 2 3 4 Checking tube feeding and NG tube placement 0 1 2 3 4 Care of acute GI bleed 0 1 2 3 4 Ileostomy/Colostomy and drain care 0 1 2 3 4 Abdominal wounds or infections 0 1 2 3 4 Pre/post-op GI Surgery 0 1 2 3 4 Dehiscence 0 1 2 3 4 Care of patient on Total Parenteral Nutrition 0 1 2 3 4 Genitourinary / RenalAbility to insert/maintain urinary drainage tubes 0 1 2 3 4 Care of patient with: Acute renal failure 0 1 2 3 4 Care of patient with: Chronic renal failure 0 1 2 3 4 Care of patient with: Post renal/genitourinary surgery 0 1 2 3 4 Caring for a patient recovering from Peritoneal dialysis 0 1 2 3 4 Caring for a patient recovering from Hemodialysis 0 1 2 3 4 Assessment of fluid and electrolyte problems 0 1 2 3 4 Knowledge of UA values 0 1 2 3 4 Managing urostomy 0 1 2 3 4 Managing suprapubic catheter 0 1 2 3 4 Placing condom catheter 0 1 2 3 4 Collecting specimens 0 1 2 3 4 EndocrineCaring for a diabetic patient 0 1 2 3 4 Administration of IV insulin drip 0 1 2 3 4 Capillary blood glucose checks 0 1 2 3 4 Hormone therapy 0 1 2 3 4 OncologyCaring for AIDS patient 0 1 2 3 4 Isolation/Universal precautions 0 1 2 3 4 Pain management 0 1 2 3 4 Mixing/Administering chemo agents 0 1 2 3 4 MusculoskeletalTraction 0 1 2 3 4 Braces 0 1 2 3 4 Casts 0 1 2 3 4 Collars 0 1 2 3 4 Slings 0 1 2 3 4 Splints 0 1 2 3 4 Skeletal traction 0 1 2 3 4 Skin traction 0 1 2 3 4 Using T.E.N.S. unit 0 1 2 3 4 Beds i.e. Clinitron, Roto Rest 0 1 2 3 4 Total knee replacement 0 1 2 3 4 Total hip replacement 0 1 2 3 4 Crutch walking/walkers 0 1 2 3 4 Care of patient with: Joint disorders 0 1 2 3 4 Care of patient with: Bone disorders 0 1 2 3 4 Care of patient with: Amputation 0 1 2 3 4 Caring for patient on CPM 0 1 2 3 4 MicellaneousPain management 0 1 2 3 4 Burn patients 0 1 2 3 4 Inserting IV’s/IV therapy 0 1 2 3 4 Set-up for Cut Down 0 1 2 3 4 Performing complex dressing changes 0 1 2 3 4 Administration of blood and blood products 0 1 2 3 4 Administering and monitoring IV Anticoagulants 0 1 2 3 4 Obtaining peripheral venous blood 0 1 2 3 4 Obtaining blood from central venous line 0 1 2 3 4 Knowledge of Serum Lab Values: Chem 7, Chem 10 0 1 2 3 4 Knowledge of Serum Lab Values: CBC 0 1 2 3 4 Knowledge of Serum Lab Values: Serum Drug Levels 0 1 2 3 4 IV Therapy 0 1 2 3 4 Care of drains/tubes (i.e. hemovac, etc.) 0 1 2 3 4 Monitoring and assessing I & O 0 1 2 3 4 Using PCA System 0 1 2 3 4 Using SCD or Venidyne Devices 0 1 2 3 4 Using PICC, Hickman, Central Line 0 1 2 3 4 Providing for safe patient environment 0 1 2 3 4 Experience AreasMedical/Surgical Yes Years / Months Telemetry/Stepdown Yes Years / Months Ortho Yes Years / Months Rehabilitation Yes Years / Months Mother - Baby Yes Years / Months Oncology Yes Years / Months Neurology Yes Years / Months Pediatrics Yes Years / Months Urology Yes Years / Months Skilled Yes Years / Months Hospice Yes Years / Months General Medicine Yes Years / Months General Surgery Yes Years / Months Charge Experience Yes Years / Months IV Certified Yes Years / Months Other Yes Type: Years / Months 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 Medical / Surgical Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.