Pediatric 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 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.Your NameYour NameYour NameYour Name
