SunbeltStaffing.com Skills Self Assessment

Medical Surgical
Skills Self Assessment

This skills assessment is designed to determine your level of competency in the areas listed below. By completing this checklist to the best of your ability, you will help us match your skills and areas of interest with our available assignments. Please indicate your appropriate level for each category as well as the date last performed.

Traveler Name:
Traveler Email:
Recruiter Name:
Date:

COMPETENCY LEVELS	DATE LAST PERFORMED
1 = Functionally Independent	Within 6 Months
2 = Some Experience	6 mo. - 12 mo. ago
3 = Minor or No Experience	Over 1 year ago
	Not Performed / Never Worked

Please check appropriate box: RN LPN
Skills	Competency Level	Date Last Performed
CARDIOVASCULAR
Abdominal Aortic Bypass
Aneurysm
Angina
Angioplasty
Cardiac Arrest
Cardiac Cath (Pre/Post)
Cardiac Monitors
Cardiomyopathy
Carotid Endarterectomy
Congestive Heart Failure
Defibrillation / Cardioversion
Femoral - Popliteal Bypass
Myocarditis
Pacemaker (Permanent)
Pacemaker (Temporary)
Post Acute MI
Telemetry:
1. 12 lead interpretation
2. Arrhythmia interpretation
3. Lead placement
Thrombophlebitis
GASTROINTESTINAL
Abdominal Wounds / Drains
Bowel Obstruction
Bowel Sounds
Colostomy Care
Enemas
Enterostomal Care
Esophageal Bleeding
Gastrostomy Tube
GI Distress / Bleeding
Jejunostomy Tube
Liver Transplant
NG Tube
Pancreatitis
Paralitic Ileus
GYNECOLOGY
Abdominalplasty
Ectopic Pregnancy
Endometriosis
GYN Exam / Pap
Hysterectomy
Mastectomy
Reconstructive Breast Surgery
Removal of Cysts
Self Breast Exam
Tubal Ligation
INFECTIOUS DISEASE
AIDS
Fever Management
Hepatitis
Interpretation of Lab Results
Isolation
NEUROLOGY
Aneurysm Precautions
Assessment of Neuro Signs
Assist with Lumbar Puncture
AV-Shunt Placement (post)
Basal Skull Fracture
Cranial Hemorrhage
CVA
Encephalitis
Glasgow Coma Scale
Meningitis
Multiple Sclerosis
Neuro Injury / Trauma
Neuro Surgery (Pre / Post)
Overdose
Seizure Activity
Spinal Cord Injury
VASCULAR
Administration of Blood / Products
Air Occlusive Dressing
Anaphylaxis
Anasarca
Arteriovenous
Burns
Cellulitis
Deep Vein Thrombosis
Fluid Overload
Groshong Catheters
Hemodialysis
Heparin Drip (Precaution & Maint.)
Hickman / Broviac Catheters
Infusion Pumps
Initiating IV Access
Maintenance of Heparin Lock
Normal Serum Lab Valves
Peripheral Pulses
Peripheral Dialysis
Quiton / Permacaths
Septic Shock
Shunt
Sickle Cell Anemia
Stasis Ulcers
Surgical Wound Healing
Surgical Wounds with Drains
Traumatic Wounds
Wound Care / Irrigations
RESPIRATORY
ARDS
Assisting with Intubation
Asthma
Chest Tubes
COPD
Emphysema
Endotracheal Suctioning
Incentive Spirometry
Inhalation Injuries
Interpretation of ABG
Nasal Suctioning
Oral Suctioning
Oxygen Administration
Pneumothorax
Pneumonia
Pulmonary Edema
Pulmonary Embolism
Pulse Oximetry
Thoracic Surgery (Pre / Post)
Tracheostomy Suctioning
Use of IPPB
Ventilators Type:
Bear I
Bear II
Bear V
Bennett 7200
CPAP
Emerson
Engstrom/Erica
EMV
MA-IMA-II
Monihan
Ohio 560
PEEP
Presure Pre-Set
Servo 900b
Servo 900c
Servo 900e
Siemens
Other (list):
Other (list):
Other (list):
RENAL
Chronic / Acute Renal Failure
Catheter Care
Electrolyte Imbalance / Replacement
Foley Catheter
GU Irrigations
Hemodialysis
Nephrectomy
Nephrostomy Tube
Peritoneal Dialysis
Radical Prostectomy
Renal Calculi
Renal Transplant
Renal Trauma
Shunts and Fistulas
Suprapubic Catheter
ONCOLOGY
Blood Chemistry Interpretation
Blood Count Interpretation
Bone Marrow Transplant
Chemotherapy
Fresh Oncologic Surgery
Inpatient Hospice
Leukemia
Radiation Implant
Reverse Isolation
ORTHOPEDIC
Amputation
Arthroscopic Surgery (Pre / Post)
Bucks Extension
Cast Care
Laminectomy
Orthopedic Trauma
Pin Site Care
Removal of Hardware
Spika Cast / Body Cast
Total Hip Replacement
Total Joint Replacement
Total Knee Replacement
MED ADMIN. /IV THERAPY
Unit Dose
Pediatric conversions
IV additives & piggybacks
Intramuscular Injections
Intradermal Injections
Subcutaneous Injections
IV Pushes
Epidural Pumps
PCA Pumps
Infusion Pumps
Coumadin Therapy
Heparin Locks
Emergency Drugs
USE & ADMINISTRATION OF THE FOLLOWING:
Atropine
Digoxin
Inderal
NTG
Pronestyl
Quinidine
Verapamil
Thrombolytic Agents
Aminophylline
Corticosteroids
Bronkosol
Ventolin
Alupent
Decadron
Dilantin
Magnesium Sulfate
Phenobarbital
Steroids
Valium
Versed
CARDIAC MONITORS
Hewlett-Packard
Spacelab
Siemens
Marquette
Mennen
Lifecare
Nihon-Koder
Please list any licenses or certifications held and when they expire:

Please list any area of competence (techniques, procedures, technologies, skills, etc.) where you would like to pursue additional training in order to enhance the level of care, treatment, or services to the population(s) that you serve:

Age Specific Competency

Please indicate the appropriate level for each category. When evaluating your competency level, please focus on the following guidelines:

Ability to ensure a safe and caring environment for the specific age groups indicated below.
Ability to communicate and instruct patients in the designated age groups.
Ability to evaluate age-appropriate behavior and skills.

Age Group	Competency Level	Date Last Performed
Newborn (birth-30 days)
Infant (30 days-1 yrs)
Toddler (1-3 yrs)
Preschooler (3-5 yrs)
School Age (5-12 yrs)
Adolescents (12-18 yrs)
Young Adults (18-39 yrs)
Middle Adults (39-64 yrs)
Older Adults (64 yrs +)

To the best of my knowledge, the information represented above is an accurate reflection of my skills and abilities, and I authorize Sunbelt Staffing to share the above skills checklist with its clients.