AMBULATORY SKILLS CHECKLIST
  AMBULATORY SKILLS CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

 
       
Rating Stars (Click) General Patient Care 1 2 3 4  
Admit and Assess Patients  
Advance Directives  
Collect Appropriate Data  
Discharge Teaching  
Preoperative Teaching  
Patient Prep  
Computerized Documentation  
Rating Stars (Click) Cardiovascular 1 2 3 4  
Assess Heart Tones  
Bedside Tele Monitoring  
Interpretation of Coagulation Studies  
Perform Pulses/Circulation Checks  
Pre/Post Op Care Pacemaker  
Rating Stars (Click) Pulmonary 1 2 3 4  
Assess Breath Sounds  
Apply Oxygen  
Interpret ABGs  
Thoracentesis  
Oximetry  
Rating Stars (Click) Neurology 1 2 3 4  
Assess Neurological Signs  
Epidurals  
Selective Nerve Root Blocks  
Level of Consciousness  
Rating Stars (Click) GI 1 2 3 4  
Insertion/Monitoring NG Tubes  
Assessment/Patient Care Continued  
Flexible Sigmoidoscopy  
Hemorrhoid Banding  
Liver Biopsy  
Paracentesis  
Lap Band Surgery  
Rating Stars (Click) GU 1 2 3 4  
Bladder Biopsy  
Cystoscopy  
Urethral Dilation  
Nephrostomy  
Kidney Biopsy  
Suprapubic Catheter  
Prostate Biopsy  
Rating Stars (Click) Endocrine 1 2 3 4  
Care of Diabetic Patient  
Diabetic Teaching  
Rating Stars (Click) ENT and Mouth 1 2 3 4  
Prosthondontics – Restorative Dentistry  
Mouth Biopsy  
Myringotomy  
Maxillofacial Prosthetics  
Nose Biopsy  
Thyroid Aspirate Biopsy  
Fiberoptic Laryngoscopy  
Tonsilectomy  
Rhinoplasty  
Rating Stars (Click) Wounds/Integument 1 2 3 4  
Application of Burn Dressings  
Application of Dressing  
Debridement of Wound  
Wound Care  
Rating Stars (Click) OB/GYN 1 2 3 4  
Electrodesiccation and Curettage (ED&C)  
Nipple Reconstruction  
Rating Stars (Click) Musculoskeletal 1 2 3 4  
Arthrocentesis  
External Hardware and Pin Care  
Arthroscopy  
Open Reduction and Internal Fixation  
Closed Reduction and Internal Fixation  
Trigger Point Injections  
Rating Stars (Click) Plastics 1 2 3 4  
Liposuction  
Plastic Surgery  
Cosmetic  
Rating Stars (Click) General Medications/Therapeutic Interventions 1 2 3 4  
Administer IM and SQ Meds  
Administer Inhalation Medications  
Administer PO Medications  
Bladder Irrigation and Instillation  
Needleless Systems  
Chemotherapy  
Rating Stars (Click) IV Therapy 1 2 3 4  
Infusion Pumps  
Peipheral IV Insertion  
Syringe Pumps  
Vascular Access Devices Care/Maintenance  
Administer IV Medications  
Rating Stars (Click) Oxygen Administration 1 2 3 4  
Ambu-Bug  
Nasal Cannula  
Non-ReBreather Mask  
Pulse Oximetry  
Venti Mask  
Face Mask  
Rating Stars (Click) Nutritional Therapy 1 2 3 4  
Lipids  
TPN  
Procalamine  
Enteral Administration  
Rating Stars (Click) Pain Management/Anesthesia 1 2 3 4  
Inplantable Narcotic Pump Re ll  
Moderate Sedation  
Epidural  
Spinal  
Local  
General  
Axillary Block  
Bier Block  
Rating Stars (Click) Blood 1 2 3 4  
Blood and Blood Products  
Albumin  
Rating Stars (Click) General Procedures/Equipment 1 2 3 4  
Apply Immobilizers (clavicle, knee, etc.)  
Assist with Code Resuscitation  
Assist with Lumbar Puncture  
Laser  
Dermabrasion  
Drain Removal  
Incision and Drainage  
NGT Insertion  
Patch Test  
Punch Biopsy  
Procedure Set Up  
Procedures/Equipment Continued  
Remove External Fixators With Pin  
Scissor Biopsy  
Scrub  
Screw-Hardware Removal  
Set-up Assist Suturing  
Staple Removal  
Straight/Foley Cath Female  
Straight/Foley Cath Male  
Suture Removal  
TENS (Transcutaneous Elec. Nerve Stimulator)  
Use of Doppler    
Rating Stars (Click) Specimen Collections 1 2 3 4  
Venipuncture  
Clean Catch Urine  
Sterile Urine Collection  
Stool  
Sputum  
Butter y Stick  
Central Line Draw  
Rating Stars (Click) Clinical Settings 1 2 3 4  
Surgi-Center  
Out Patient Clinic  
Age Group Experience Continued  
Physician O ce  
Ambulatory Surgery Clinic  
Rating Stars (Click) Joint Commission 1 2 3 4  
National Safety Goals  
“Do Not Use” Abbreviations and Terms  
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Infant (Birth - 1 year)  
Preschooler (ages 2-5 years)  
Childhood (ages 6-12 years)  
Adolescents (ages 13-21 years)  
Young Adults (ages 22-39 years)  
Adults (ages 40-64 years)  
Older Adults (ages 65-79 years)  
Elderly (ages 80+ years)