NICU 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 independentlyPatient TypesNeonates < 28 Weeks 1 2 3 4 Neonates 29 - 34 Weeks 1 2 3 4 Neonates > 34 Weeks 1 2 3 4 Work SettingsLevel II NICU 1 2 3 4 Level III NICU 1 2 3 4 Level IV NICU 1 2 3 4 CardiovascularCardiac Surgery - Pre-op 1 2 3 4 Cardiac Surgery - Immediate Post-op 1 2 3 4 Congenital Heart Disease/Defects 1 2 3 4 CHF/Pulmonary Edema 1 2 3 4 Hemodynamic Instability 1 2 3 4 PulmonaryBronchopulmonary Dysplasia 1 2 3 4 Diaphragmatic Hernia 1 2 3 4 Fresh Tracheostomy 1 2 3 4 Meconium Aspiration 1 2 3 4 Persistent Pulmonary Hypertension 1 2 3 4 Pneumonia 1 2 3 4 Respiratory Distress Syndrome/Failure 1 2 3 4 Interpretation of ABGs 1 2 3 4 Assist with Intubation/Extubation 1 2 3 4 Endotracheal Suctioning 1 2 3 4 Chest Tube Placement and Management 1 2 3 4 Modes of Ventilation (AC/PC/SIMV/CPAP/BiPAP) 1 2 3 4 High Frequency Ventilation 1 2 3 4 Inhaled NO 1 2 3 4 ECMO 1 2 3 4 NeurologicBallard/Dubowitz 1 2 3 4 Reflexes Based on Gestational Age 1 2 3 4 Hydrocephalus 1 2 3 4 Intraventricular Hemorrhage 1 2 3 4 Meningocele/Myelomeningocele 1 2 3 4 Neonatal Abstinence Score/Syndrome 1 2 3 4 Seizures 1 2 3 4 GastrointestinalColostomy/Ileostomy 1 2 3 4 Gastroschisis/Omphalocele 1 2 3 4 GI Bleeding 1 2 3 4 Necrotizing Enterocolitis 1 2 3 4 Post Abdominal Procedure 1 2 3 4 FeedingsBreast Milk Handling/Storage 1 2 3 4 Breast Pump 1 2 3 4 Gavage Feedings 1 2 3 4 NG/OG/NJ Tube Placement and Management 1 2 3 4 Renal / Endocrine / GeneticCircumcision Care 1 2 3 4 Genetic Disorders 1 2 3 4 Hypo/Hyperglycemia 1 2 3 4 Infant of Diabetic Mother 1 2 3 4 Malformations of the GU Tract/Kidney 1 2 3 4 Phototherapy 1 2 3 4 Renal Failure 1 2 3 4 Infectious DiseasesNeonatal Sepsis 1 2 3 4 Septic Work Up 1 2 3 4 Assist with Lumbar Puncture 1 2 3 4 MedicationsCalculation of Neonatal Dosages 1 2 3 4 Antibiotics/Antivirals 1 2 3 4 Anticonvulsants 1 2 3 4 Immunizations 1 2 3 4 Digoxin 1 2 3 4 Prostaglandin 1 2 3 4 Bronchodilators 1 2 3 4 Steroids 1 2 3 4 Caffeine 1 2 3 4 Surfactant 1 2 3 4 Automated Medication Dispensing (i.e. Pyxis,Omnicell) 1 2 3 4 IV TherapyAdministration of Blood/Blood Products 1 2 3 4 Central Line Catheter/Dressings 1 2 3 4 Management of UAC/UVC Lines 1 2 3 4 Radial Arterial Lines 1 2 3 4 Start IVs 1 2 3 4 Cardiac Monitoring & Emergency ResponseAttend High Risk Deliveries 1 2 3 4 Preparation for Transport 1 2 3 4 Transport Neonate 1 2 3 4 Rhythm Interpretation 1 2 3 4 Dysrhythmia Management 1 2 3 4 Professional Knowledge and SkillsNational Patient Safety Goals/Core Measures 1 2 3 4 Bereavement/Postmortem Care 1 2 3 4 Neonatal Skin Care 1 2 3 4 Pressure Ulcer Risk Assessment/Prevention 1 2 3 4 Restraints/Use of Least Restrictive Device 1 2 3 4 Patient/Family Teaching 1 2 3 4 Age Specific/Population-Based Care 1 2 3 4 Isolation Precautions 1 2 3 4 Infection Prevention 1 2 3 4 Pain Assessment & Management 1 2 3 4 Charge Experience 1 2 3 4 Interpretation and Communication of Lab Values 1 2 3 4 EMRCerner 1 2 3 4 Eclipsys 1 2 3 4 Epic 1 2 3 4 McKesson 1 2 3 4 Meditech 1 2 3 4 Other Computerized System 1 2 3 4 Computerized Physician Order Entry 1 2 3 4 Bar Coding for Medication Administration 1 2 3 4 EMR Conversion Yes CertificationsBLS Yes BLS Expiration Date Month Day Year NRP Yes NRP Expiration Date Month Day Year PALS Yes PALS Expiration Date Month Day Year S.T.A.B.L.E Yes S.T.A.B.L.E Expiration Date Month Day Year NCC Certification - RNC-NIC Yes NCC Certification - RNC-NIC Expiration Date Month Day Year Other: SpecifyOther Expiration Date Month Day Year 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 NICU Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
