Wound Care & Ostomy 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 SettingsAcute Care – Adult 1 2 3 4 Clinic – Adult 1 2 3 4 SNF/LTAC/Subacute 1 2 3 4 Hospice / Palliative Care 1 2 3 4 Acute/Long Term Care – Pediatrics 1 2 3 4 Clinic – Pediatrics 1 2 3 4 Pressure UlcersAssessment 1 2 3 4 Staging 1 2 3 4 Prevention/ Risk Assessment Tools – Adult 1 2 3 4 Prevention/ Risk Assessment Tools -Pediatrics 1 2 3 4 Support Surface Selection 1 2 3 4 Neuropathic UlcersAssessment 1 2 3 4 Management 1 2 3 4 Venous Stasis UlcersAssessment 1 2 3 4 Management 1 2 3 4 Peripheral Arterial UlcersAssessment 1 2 3 4 Ankle Brachial Index 1 2 3 4 Management 1 2 3 4 Other WoundsFistulae – Pouching / Skin Care 1 2 3 4 Skin Care/ Management of Drains 1 2 3 4 Wound DebridementAutolytic 1 2 3 4 Enzymatic 1 2 3 4 Mechanical 1 2 3 4 Sharp 1 2 3 4 Dressings/TreatmentsHydrogels 1 2 3 4 Hydrocolloids 1 2 3 4 Silver Products 1 2 3 4 Foams 1 2 3 4 Alginates 1 2 3 4 Vacuum Assisted Closure 1 2 3 4 Growth Factors 1 2 3 4 Skin Substitutes 1 2 3 4 Hyperbaric Oxygen Therapy 1 2 3 4 Wound Cultures 1 2 3 4 Electrical Stimulation 1 2 3 4 Enzymatic Debriding Agents 1 2 3 4 Mist Therapy 1 2 3 4 Colostomy/IleostomyOstomy Equipment Selection 1 2 3 4 Continence Skin Care Management 1 2 3 4 Loop with Rod Stoma 1 2 3 4 End Stoma 1 2 3 4 Mucous Fistula 1 2 3 4 Double Barrel Stoma 1 2 3 4 Irrigation 1 2 3 4 Ileal Lavage 1 2 3 4 Continent IleostomyKnock Pouch 1 2 3 4 Pelvic Pouch 1 2 3 4 Urosstomy/ContinentCatherization for C&S 1 2 3 4 Knock Pouch 1 2 3 4 Neobladder 1 2 3 4 Continence Therapeutic DevicesVaginal Cones 1 2 3 4 Penile Clamps 1 2 3 4 Male External Catheters 1 2 3 4 Internal Urethral Inserts 1 2 3 4 Catheters –Mgmt & Self Care Teaching 1 2 3 4 Magnetic Therapy 1 2 3 4 Urinary Incontinence Program 1 2 3 4 Fecal Incontinence Program 1 2 3 4 BurnsBurn Management 1 2 3 4 Professional Knowledge & SkillsNational Patient Safety Goals/ Core Measures 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 Precautions 1 2 3 4 Pain Assessment & Management 1 2 3 4 Interpretation & Communication of Lab Values 1 2 3 4 EMR 1 2 3 4 EPIC 1 2 3 4 Cerner 1 2 3 4 Eclipsys 1 2 3 4 McKesson 1 2 3 4 Other Computerized System 1 2 3 4 Computerized Physician Order Entry 1 2 3 4 Bar Coding for Medication 1 2 3 4 Culture 1 2 3 4 Other/Misc.Pain Management Assessment of Pain Levels without Intervention 1 2 3 4 Pain Management Response Assessment with Intervention 1 2 3 4 Experience: Charge Duty 1 2 3 4 Experience: Preceptor 1 2 3 4 Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Toddler (1-3 years) 1 2 3 4 Preschooler (3-6 years) 1 2 3 4 School Age (6-12 years) 1 2 3 4 Adolescent (12-18 years) 1 2 3 4 Young Adult (18-30 years) 1 2 3 4 Mature Adult (30-60 years) 1 2 3 4 Elderly (>60 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 Emergency Room RN Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
