Home Health Skills Checklist
  Home Health 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) CARDIOVASCULAR 1 2 3 4  
ACS/Post MI   
Heart Failure   
Post Cardiac Surgery  
Cardiac Auscultation (Rate/Rhythm)   
Peripheral Pulse/Circulation Checks  
Rating Stars (Click) PULMONARY 1 2 3 4  
Asthma  
COPD  
Pneumonia  
Lung Cancer  
Pulmonary Emboli  
Auscultate Lung Sounds  
Oxygen Administration   
Oxygen Safety   
Oro/Nasotracheal Suctioning   
CPAP/BiPAP   
Ventilator Management (Specify):  
Rating Stars (Click) NEUROLOGICAL 1 2 3 4  
CVA   
Alzheimer's Disease/Dementia  
Parkinson's  
Degenerative Neurologic Disorders (ALS, MS, etc.)  
Brain Tumor  
Brain Injury  
Para/Quadriplegia  
Seizure Disorder  
Level of Consciousness/Neuro Changes  
Rating Stars (Click) ORTHOPEDICS 1 2 3 4  
Joint Replacement  
DVT Prophylaxis/Recognition  
Incision Checks  
Staple Removal  
Fractures  
Cast/Brace  
Amputation  
Arthritis  
Assistive Equipment/Lift Devices  
In Home PT/INR (Specify):  
Rating Stars (Click) GASTROINTESTINAL 1 2 3 4  
Nutritional Assessment   
Colostomy/Ileostomy Management  
Fecal Incontinence/Diarrhea  
Bowel Obstruction  
GI Bleed  
Post GI Surgery  
Hepatitis Liver Failure  
NG Tubes  
Feeding Tubes  
Feeding Pumps (Specify):  
Drainage Devices  
Rating Stars (Click) RENAL/GENITOURINARY 1 2 3 4  
Hemodialysis  
AV Fistula/Shunt  
Peritoneal Dialysis  
Post Bladder Surgery  
Post Prostate Surgery  
Urostomy  
Urinary Incontinence  
Bladder Catheter Insertion/Maintenance  
Suprapubic Catheter Insertion/Maintenance  
Rating Stars (Click) ENDOCRINE/METABOLIC 1 2 3 4  
Diabetes  
Hyper/Hypoglycemia  
Diabetic Skin Assessment  
Cushing's / Addison's Disease  
Thyroid Disease  
Insulin Pumps  
Glucometers  
Rating Stars (Click) WOUND/SKIN CARE 1 2 3 4  
Braden Scale  
Pressure Ulcer Prevention  
Pressure Ulcer Staging  
Pressure Ulcer Management  
Burns  
Wound Care  
Wound Cultures  
Wound Vac  
Rating Stars (Click) ONCOLOGY 1 2 3 4  
Risk for Infection  
Symptom Management  
Side Effects of Treatment  
Terminal Disease  
Rating Stars (Click) INFECTIOUS DISEASE 1 2 3 4  
MRSA  
VRE  
C. Difficile  
HIV  
Tuberculosis  
Isolation Precautions  
Rating Stars (Click) PHLEBOTOMY/IV THERAPY 1 2 3 4  
Peripheral Venipuncture for Labs  
Start Ivs  
Peripheral Ivs  
PICC/CVP Lines  
Venous Access Ports  
Infusion Pump Set up and Management  
Specify Infusion Pump Type:  
Rating Stars (Click) PSYCHIATRIC 1 2 3 4  
Cognitive Disorders  
Mood Disorders  
Schizophrenia/Psychotic Disorders  
Medication Compliance  
Rating Stars (Click) WOMEN'S HEALTH/MATERNAL-INFANT CARE 1 2 3 4  
Pregnancy Related Complications  
Fetal Heart Tones  
Contractions  
Post Partum Mother/Baby Visit  
Newborn Care  
Phototherapy   
Breast Feeding Support  
Rating Stars (Click) PEDIATRICS 1 2 3 4  
Growth and Development  
Respiratory Distress Syndrome  
Bronchopulmonary Dysplasia  
Cystic Fibrosis  
Muscular Dystrophy  
Spina Bifida  
Spinal Surgery  
Sickle Cell Disease  
Trach Care/Suctioning  
Ventilator Management  
Ventilator Type (Specify):  
Rating Stars (Click) PAIN MANAGEMENT 1 2 3 4  
Verbal/Nonverbal Pain Scales  
Response to Pain Management Interventions   
PCA Pump   
Epidural Cath/Site Monitoring/Pump   
Non-Pharmacologic Pain Measures  
Rating Stars (Click) PALLIATIVE AND END OF LIFE CARE 1 2 3 4  
Palliative Symptom Management   
Pain Management/Response  
Family Support/Teaching  
After Death Protocols  
Rating Stars (Click) MEDICATIONS 1 2 3 4  
Alzheimer's Medications  
Antiarrhythmics  
Antibiotics/Antivirals  
Anti-Depressants  
Anti-Hypertensives  
Anti-Psychotics  
Anti-Seizure Medications  
Benzodiazepines  
Calculation of Pediatric Dosages  
Coumadin  
Diuretics  
Enoxaparin   
Inhaled Medications  
Nebulizer Medications  
Insulin  
Opioid and Non-Opioid Analgesics  
Oral Chemotherapy  
Oral Hypoglycemics  
Oral & Topics Nitrates  
Rivaroxaban  
Sedative/Hypnotics  
Steroids  
Rating Stars (Click) HOME HEALTH 1 2 3 4  
Intake/Admissions  
Case Manager  
Case Load - Pts/Day(specify)  
Supervise LVNs/HHAs   
Medicare/Medicaid  
Long/Short Term Disability  
Private Insurance  
Telephonic Assessments  
Management of Complaints  
APS Reports  
OASIS  
Diagnosis Coding  
Document Plan of Care  
Clinical Assessment Documentation  
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS 1 2 3 4  
National Patient Safety Goals/Core Measures  
Safety Assessment  
Fall Assessment and Prevention  
Patient/Family Teaching  
Age Specific/Population Based Care  
Rating Stars (Click) EMR 1 2 3 4  
Allscripts  
Cerner   
Epic  
HomeCare Home Base  
McKesson  
Meditech  
Other Computerized Documentation System  
  EMR Conversion
   
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)  
CERTIFICATIONS     Expiry Date :   
BLS  
ACLS  
PALS  
   
   
IV Certification