Pediatric 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 independentlyWork SettingsPediatric MedSurg 1 2 3 4 Pediatric Step Down/Telemetry 1 2 3 4 Pediatric Oncology 1 2 3 4 Pediatric Ortho 1 2 3 4 Pediatric Neuro 1 2 3 4 CardiovascularCongenital Heart Disease/Repair 1 2 3 4 Pre Cardiac Surgery 1 2 3 4 Post Cardiac Surgery 1 2 3 4 Heart Sounds 1 2 3 4 PulmonaryReactive Airway Disease 1 2 3 4 RSV 1 2 3 4 Tuberculosis 1 2 3 4 Esophageal Atresia 1 2 3 4 Epiglottitis 1 2 3 4 Tonsillitis 1 2 3 4 Laryngotracheobronchitis (Croup) 1 2 3 4 ENT Surgery 1 2 3 4 Oxygen Delivery Systems 1 2 3 4 Tracheostomy Management 1 2 3 4 Oral Suctioning 1 2 3 4 Deep Suctioning 1 2 3 4 Management of Chest Tubes 1 2 3 4 Apnea Monitor 1 2 3 4 Home Ventilator Therapy 1 2 3 4 Neurologic/OrthopedicBrain Injury 1 2 3 4 Spinal Cord Injury 1 2 3 4 Seizure Disorders 1 2 3 4 Meningitis 1 2 3 4 Neuromuscular Disease 1 2 3 4 Extremity Fracture/Cast 1 2 3 4 Post Vertebral Surgery 1 2 3 4 Traction - General 1 2 3 4 Traction - Halo 1 2 3 4 Pin Care 1 2 3 4 VP Shunts/Internal/External 1 2 3 4 GastrointestinalCleft Lip/Palate 1 2 3 4 Inflammatory Bowel Disease 1 2 3 4 Colostomy/Ileostomy 1 2 3 4 Surgical Drains 1 2 3 4 Failure to Thrive 1 2 3 4 Feeding Intolerance 1 2 3 4 Gastroenteritis/Dehydration 1 2 3 4 Bowel Obstruction 1 2 3 4 Short Gut Syndrome 1 2 3 4 Breastfeeding Support/Handling of Breast Milk 1 2 3 4 Renal/GenitourinaryCircumcision 1 2 3 4 Testicular Torsion 1 2 3 4 Glomerulonephritis 1 2 3 4 Renal Failure 1 2 3 4 Renal Transplant 1 2 3 4 Urinary Retention 1 2 3 4 Bladder Scan 1 2 3 4 Insertion/Management of Bladder Catheters 1 2 3 4 Management of Suprapubic Catheters 1 2 3 4 Endocrine / MetabolicDiabetes - Hypo/Hyperglycemia 1 2 3 4 Diabetic Ketoacidosis 1 2 3 4 IV Insulin Pumps 1 2 3 4 Indwelling Insulin Pumps 1 2 3 4 Hyperbilirubinemia 1 2 3 4 Bili Bed 1 2 3 4 OncologyChemotherapy Administration 1 2 3 4 Hodgkin's Disease 1 2 3 4 Hemophilia 1 2 3 4 Sickle Cell Anemia 1 2 3 4 Leukemia 1 2 3 4 Solid Tumors 1 2 3 4 Bone Marrow Transplant 1 2 3 4 Infectious DiseasesChildhood Communicable Diseases 1 2 3 4 Hepatitis 1 2 3 4 HIV 1 2 3 4 Kawasaki Disease 1 2 3 4 MedicationsPediatric Dosage Calculations 1 2 3 4 Anti-Hypertensives 1 2 3 4 Anticoagulants 1 2 3 4 Anti-Seizure Medications 1 2 3 4 Benzodiazepines 1 2 3 4 Digoxin 1 2 3 4 Diurectics 1 2 3 4 Emergency Medications 1 2 3 4 Inhaled Medications 1 2 3 4 Insulin 1 2 3 4 Narcotics/Opioid Analgesics (IV/Oral/Injection) 1 2 3 4 Non-Opioid Analgesics (IV/Oral/Injection) 1 2 3 4 Procedural Sedation - Recovery 1 2 3 4 Reversal Agents 1 2 3 4 Steroids (IV/Oral/Inhaled) 1 2 3 4 Automated Medication Dispensing (i.e. Pyxis, Omnicell) 1 2 3 4 IV TherapyStarting IVs 1 2 3 4 Central Line Blood Draw 1 2 3 4 Central Line/Implanted Line Care 1 2 3 4 TPN/Lipids 1 2 3 4 Blood Product Administration 1 2 3 4 Administration of Chemotherapy 1 2 3 4 Cardiac Monitoring & Emergency ResponsePediatric Early Warning Score (PEWS)/RapidResponse Team 1 2 3 4 Dysrhythmia Interpretation 1 2 3 4 Dysrhythmia Management 1 2 3 4 Professional Knowledge and SkillsNational Patient Safety Goals/Core Measures 1 2 3 4 Recognize/Report Signs of Abuse 1 2 3 4 Fall Risk Assessment/Prevention 1 2 3 4 Pressure Ulcer Risk Assessment/Prevention 1 2 3 4 Restraints/Use of Least Restrictive Device 1 2 3 4 Normal Growth and Development 1 2 3 4 Age Specific/Population-Based Care 1 2 3 4 Patient Family Teaching 1 2 3 4 Isolation Precautions 1 2 3 4 Infection Prevention 1 2 3 4 Reporting Communicable Diseases 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 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 CertificationsBLS Yes BLS Expiration Date Month Day Year PALS Yes PALS Expiration Date Month Day Year CPHON Yes CPHON Expiration Date Month Day Year Chemo Certification: SpecifyChemo Certification Expiration Date Month Day Year PICC Certification: SpecifyPICC Certification Expiration Date Month Day Year Other: SpecifyOther Certification Expiration Date Month Day Year Other: SpecifyOther Certification 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 Pediatric Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
