* = Required Information
This assessment is for determining your experience in the below outlined clinical areas. This checklist will not be used as a determining factor in accepting your application to become an employee of PACE Medical Staffing, Inc.
PROFICIENCY SCALE
1. No Experience
2. Need Training
3. Able to perform with supervision
4. Able to perform independently
Proficiency Scale
Orthopedic
Cast Care
1
2
3
4
Crutch Walking
1
2
3
4
K wires
1
2
3
4
Traction
1
2
3
4
Neurology
Aneurysm Precautions
1
2
3
4
Assist with Lumbar Puncture
1
2
3
4
Glascow Coma Scale
1
2
3
4
Intracranial Pressure Monitoring
1
2
3
4
Neuro Assessment/Vital Signs
1
2
3
4
Seizure Precautions
1
2
3
4
Respiratory
Assist with Intubation (ETT)
1
2
3
4
Establish Airway
1
2
3
4
ETT Extubation
1
2
3
4
Incentive Spirometry
1
2
3
4
Suctioning
1
2
3
4
Ventilate with Ambu-bag
1
2
3
4
Meds/IV Therapy
Administer IM & SQ Meds
1
2
3
4
Administer IV Medications
1
2
3
4
Administer NG/GT Meds
1
2
3
4
Administer PO Medications
1
2
3
4
Discontinue Peripheral IV's
1
2
3
4
Infusion Pumps
1
2
3
4
Intra Catheter
1
2
3
4
Mix IV Meds
1
2
3
4
Mix IV Infusion w/ Additives
1
2
3
4
Needle-less systems
1
2
3
4
Pain Assessment/Management
1
2
3
4
Peripheral IV Insertion
1
2
3
4
Use of Heparin/Saline Locks
1
2
3
4
Genitourinary
GU Irrigations
1
2
3
4
Hemodialysis
1
2
3
4
Hysterectomy
1
2
3
4
Nephrostomy Tube
1
2
3
4
Obtain/Instruct Clean Catch Urine
1
2
3
4
Nephrostomy Tube
1
2
3
4
Peritoneal Dialysis
1
2
3
4
Prostate Surgery
1
2
3
4
Renal Tranplant
1
2
3
4
Straight/Foley Cath Female
1
2
3
4
Straight/Foley Cath Male
1
2
3
4
Suprapubic Tube
1
2
3
4
Post-Anesthesia Care
AIDS
1
2
3
4
Block
1
2
3
4
Bone Marrow Transplant
1
2
3
4
Burn Patients
1
2
3
4
Chemotherapy
1
2
3
4
Diabetic Teaching/Care
1
2
3
4
General
1
2
3
4
Liver Transplant
1
2
3
4
Multiple Trauma Patient
1
2
3
4
Oncology
1
2
3
4
Postmortem Care
1
2
3
4
Spinal
1
2
3
4
Cardiac
Arterial Lines
1
2
3
4
Assist with Code
1
2
3
4
Cardiac Arrest/ CPR
1
2
3
4
Central Venous Pressure Readings
1
2
3
4
Defibrillation/Cardioversion
1
2
3
4
Interpretation of Arrhythmias
1
2
3
4
Perform 12- Lead EKG
1
2
3
4
Telemetry
1
2
3
4
Use of Cardiac Monitors
1
2
3
4
General Nursing
Admit & Orient Patients
1
2
3
4
Advance Directives
1
2
3
4
Blood Glucose Monitoring
1
2
3
4
Discharge Patients
1
2
3
4
Dressing Changes
1
2
3
4
Isolation Techniques
1
2
3
4
Positioning/Transferring
1
2
3
4
Pulse Oximetry
1
2
3
4
Restraints
1
2
3
4
Supervise Unlicenses Personnel
1
2
3
4
Urine Dipstick
1
2
3
4
Vital Sign Monitoring
1
2
3
4
Wound Care/Debridement
1
2
3
4
Wound Drains (JP/Hemovac)
1
2
3
4
Gastrointestinal
Assess Bowel Sounds
1
2
3
4
Assess GI Distress/Bleeding
1
2
3
4
Chest Percussion
1
2
3
4
Chest Tubes
1
2
3
4
Colostomy Care
1
2
3
4
Enemas
1
2
3
4
Face Masks
1
2
3
4
Gastrostomy Tube Monitor/Feed
1
2
3
4
Insertion/Monitoring NG Tubes
1
2
3
4
Interpret ABG's
1
2
3
4
Nasal Cannula
1
2
3
4
Obtain Arterial Blood Gases (ABG's)
1
2
3
4
Tube Feedings via Flexible Tubes
1
2
3
4
Ventilators
1
2
3
4
Vascular
Administer Blood & Blood Products
1
2
3
4
Assess for Edema/Fluid Overload
1
2
3
4
Central Venous Lines (CVL)
1
2
3
4
CVL's Dressing Change
1
2
3
4
Draw Blood for Lab Studies
1
2
3
4
Hickman/Broviac Catheters
1
2
3
4
Hyperalimentation/TPN
1
2
3
4
Intake and Output
1
2
3
4
Peripheral Pulses
1
2
3
4
Ultrasonic Doppler
1
2
3
4
Care of Patient with:
Acute MI
1
2
3
4
Amputation
1
2
3
4
Aneurysm
1
2
3
4
Arthroscopy/Arthrotomy
1
2
3
4
Asthma/COPD
1
2
3
4
Congestive Heart Failure
1
2
3
4
Craniotomy
1
2
3
4
CVA
1
2
3
4
Drug Overdose/DT's
1
2
3
4
Heart Transplant
1
2
3
4
Nephrectomy
1
2
3
4
Open/Closed Head Injury
1
2
3
4
Permanent Pacemaker
1
2
3
4
Pre/Post Cardiac Cath
1
2
3
4
Pre/Post Cardiac Surgery
1
2
3
4
Pre/Post Thoracic Surgery
1
2
3
4
Pre-Operative Care/Preparation
1
2
3
4
Pulomonary Emboli
1
2
3
4
Renal Failure
1
2
3
4
Shunts & Fistulas
1
2
3
4
Skeletal traction
1
2
3
4
Spinal Cord Injury
1
2
3
4
Temporary Pacemaker
1
2
3
4
Total Hip Replacement
1
2
3
4
Total Knee Replacement
1
2
3
4
Tracheostomy
1
2
3
4
Age Specific Competency
Able to ensure a safe and caring environment for the specific age groups indicated below; able to communicate and instruct patients from various age groups; able to evaluate age-appropriate behavior and skills.
Newborn (birth-30 days)
1
2
3
4
Infant (30 days-1 yrs)
1
2
3
4
Toddler (1-3 yrs)
1
2
3
4
Preschooler (3-5 yrs)
1
2
3
4
School Age (5-12 yrs)
1
2
3
4
Adolescents (12-18 yrs)
1
2
3
4
Young Adults (18-39 yrs)
1
2
3
4
Middle Adults (39-64 yrs)
1
2
3
4
Older Adults (64 yrs +)
1
2
3
4
The information represented above is true and correct to the best of my knowledge. I also authorize PACE Medical Staffing, Inc. to share the above skills checklist with its hospital clients.
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