* = Required Information
Last Name
*
First Name
*
Middle I.
Please mark the corresponding experience level for each section
A - Able to perform without any supervision
B - Perform infrequently (would require some supervision)
C - No experience (Require Assistance / Supervision)
A. CARDIAC
EXPERIENCE LEVEL
1. Use of cardiac monitors
A
B
C
2. Assessment of heart sounds
A
B
C
3. Cardiac Arrest
A
B
C
4. CPR
A
B
C
5. Care of patients with CHF
A
B
C
6. Atropine administration
A
B
C
7. Digoxin administration
A
B
C
8. Dopamine administration
A
B
C
9. Inderal administration
A
B
C
10. Lidocaine administration
A
B
C
B. GENITOURINARY
EXPERIENCE LEVEL
1. Fluid Balance
A
B
C
2. Foley Catheter Insertion
A
B
C
3. Ileostomy
A
B
C
4. GU Irrigations
A
B
C
5. Nephrostomy Tube
A
B
C
C. ENDOCRINE
EXPERIENCE LEVEL
1. Blood Glucose Checks
A
B
C
2. Insulin Administration
A
B
C
3. Care of patients with Diabetes
A
B
C
D. GASTROINTESTINAL
EXPERIENCE LEVEL
1. NG tube care and feedings
A
B
C
2. Gastrostomy tube care and feedings
A
B
C
3. Colostomy Care
A
B
C
4. Assessment of Bowel Sounds
A
B
C
E. LEADERSHIP/PATIENT CARE
EXPERIENCE LEVEL
1. Taking Charge
A
B
C
2. Admission Procedures
A
B
C
3. Discharge Procedures
A
B
C
4. Patient Education
A
B
C
5. Patient Care Plans
A
B
C
F. MEDICATIONS/IV THERAPY
EXPERIENCE LEVEL
1. Medication Calculation
A
B
C
2. Reconstitution
A
B
C
3. Oral Administration
A
B
C
4. Eye Administration
A
B
C
5. IM Administration
A
B
C
6. SQ Administration
A
B
C
7. Rectal Administration
A
B
C
8. Starting IV's
A
B
C
9. IV Medication Administration
A
B
C
10. Central Line Care
A
B
C
G. NEUROLOGY
EXPERIENCE LEVEL
1. Assessment of Neurological Status
A
B
C
2. Seizure Precautions
A
B
C
3. Care of a patient with a CVA
A
B
C
4. Care of a patient with Alzheimer's
A
B
C
5. Care of patients with Spinal Cord Injury
A
B
C
6. Decadron Administration
A
B
C
7. Dilantin Administration
A
B
C
8. Phenobarbital Administration
A
B
C
9. Valium Administration
A
B
C
H. ORTHO/SKIN
EXPERIENCE LEVEL
1. Assessment of skin
A
B
C
2. Wound Care and Treatments
A
B
C
3. Use of special pressure relief devices
A
B
C
4. Care of pts with a total hip replacement
A
B
C
5. Care of pts with a total knee replacement
A
B
C
6. Crutch Walking
A
B
C
I. RESPIRATORY
EXPERIENCE LEVEL
1. Pulse Oximetry
A
B
C
2. Oxygen Administration via nasal cannuia
A
B
C
3. Oxygen Administration via face mask
A
B
C
4. Principles of chest percussion
A
B
C
5. Care of patients with ventilator
A
B
C
6. Care of patients with COPD
A
B
C
7. Care of patients with ARDS
A
B
C
8. Care of patient with a Tracheotomy
A
B
C
The information that I have given is accurate and true to the best of my knowledge. I hereby authorize Pace Medical Staffing, Inc. to release same to her client health care facilities.
Signature
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Date
Submit