Skilled Nursing Checklist
  Skilled Nursing 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 Skills 1 2 3 4  
Advanced directives  
Awareness of HCAHPS  
Patient/family teaching  
Discharge planning  
UR/medicare review  
Lift/transfer devices  
Specialty beds  
Restrictive devices (restraints)  
End of life care/palliative care  
Automated Medication Dispensing System, Pyxis, Omnicell, or other  
National Patient Safety Goals  
Accurate patient identification  
Effective communication  
Awareness of patient rights  
Interpretation & communication of lab values  
Medication administration  
Labeling (medications & specimens)  
Medication reconciliation  
Anticoagulation therapy  
Pain assessment & management  
Infection control  
Universal precautions  
Isolation  
Minimize risk for falls  
Prevention of pressure ulcers  
Rating Stars (Click) Cardiac 1 2 3 4  
Assessment of heart sounds  
Identification of arrhythmias (rate/rhythm)  
Pacemakers/AID’s  
Cardiac arrest/CPR  
Hypertension  
Pre/post MI  
CHF  
Post cardiac surgery  
Fluid & electrolyte imbalances  
  Medication Administration    
Anticoagulants  
Antiarrhythmics  
Beta blockers  
Nitroglycerin  
Diuretics  
Rating Stars (Click) Respiratory 1 2 3 4  
Assessment/auscultation of lung sounds  
Establishing an airway  
Chest PT  
Incentive spirometry  
Supplemental oxygen (cannula, facemask)  
Tracheostomy care  
Suctioning (tracheostomy & nasotracheal)  
Nebulizer use  
  Care of Patient with:    
Pneumonia  
Asthma  
COPD  
Emphysema  
  Use & Administration of:    
Bronchodilators  
Expectorants  
Corticosteroids  
Rating Stars (Click) Neurology 1 2 3 4  
Assessment of neuro signs  
Seizure precautions  
  Care of Patient with:    
TBI (Traumatic Brain Injury: history of)  
Seizure activity  
Spinal cord injury  
Stroke (CVA)  
Multiple sclerosis  
Alzheimer’s disease  
Parkinson’s disease  
ALS (Amyotrophic Lateral Sclerosis)  
  Use & Administration of:    
Antiseizure medications  
Antiemetics  
Laxatives  
Enemas  
Bowel prep  
Rating Stars (Click) Gastrointestinal 1 2 3 4  
NG tube (insertion/removal)  
Long term feeding tubes (dobhoff/keofeed)  
Gastrostomy tube  
Tube feedings  
Monitoring input/output  
  Care of Patient with:    
Colostomy/ileostomy  
GI bleed  
Feeding devices/adaptive equipment  
Dietary restrictions  
GT/PEG feedings  
  Use & Administration of:    
Antiemetics  
Laxatives  
Enemas  
Bowel prep  
Rating Stars (Click) Gastrointestinal 1 2 3 4  
Foley catheter insertion/removal  
GU irrigations  
Nephrostomy tube  
Suprapubic catheter  
Ileo conduit  
Use of bladder scan equipment  
  Care of Patient with:    
Shunts and fistulas  
Straight catheterizations  
Incontinence/bladder training  
Chronic renal failure/dialysis  
Peritoneal dialysis  
Rating Stars (Click) Orthopedic 1 2 3 4  
Total joint replacement  
Arthroscopic surgery  
Cast care  
Pulse/CMS checks  
Suture/staple removal  
Prosthesis application  
Standard extremity braces  
  Care of Patient with:    
Amputation  
Stump wrapping  
Laminectomy  
Assistive devices  
CPM machines  
Rating Stars (Click) IV Therapy 1 2 3 4  
Start & maintain Ivs  
Blood draw: venous  
Central line care (PICC)  
Blood draw: central line PICC  
Care & management of ports  
Infusion pumps  
Administration of blood/blood products  
Rating Stars (Click) Skin 1 2 3 4  
Wound care/surgical  
Wound care/medical  
Dressing changes  
Skin assessment  
Wound vac  
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Newborn/neonate (birth-30 days)  
Infant (31 days-1 year)  
Toddler (2-3 years)  
Preschool (ages 4-5 years)  
School age (ages 6-12 years)  
Adolescents (ages 13-21 years)  
Young adult (ages 22-39 years)  
Adults (ages 40-64 years)  
Older adult (ages 65-79 years)  
Elderly (ages 80+ years)  
  Please list any Additional Skills:  
1  
2  
3  
4  
  Additional training:  
1  
2  
3  
4  
  Additional equipment:  
1  
2  
3  
4