Travel Nursing 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) CARDIAC 1 2 3 4  
Acute Coronary Syndrome  
Congestive Heart Failure  
Post Open Heart (12-24 hours)  
Carotid Endarterectomy  
Post Vascular Surgery  
Heart Transplant  
Pacemaker - Temporary/Permanent  
Pacemaker - Epicardial  
Sheath Removal  
Heart Sounds  
Rating Stars (Click) PULMONARY 1 2 3 4  
Pneumonia  
Respiratory Distress  
COPD  
Breath Sounds  
Post Thoracic Surgery  
Chest Tube Placement & Management  
Trach Management  
Modes of Ventilation (AC/PC/SIMV/CPAP)  
Intubation/Extubation  
External CPAP/BiPAP  
Interpretation of Arterial Blood Gases  
Rating Stars (Click) NEUROLOGIC & PSYCHIATRIC    
Stroke Scale Assessment  
CVA  
Brain Injury  
Post Craniotomy  
Spinal Cord Injury  
Seizure Disorders  
ETOH/Drug Withdrawal  
Rating Stars (Click) GASTROINTESTINAL    
GI Bleeding  
GI Surgery  
Liver Failure  
Pancreatitis  
Liver Transplant  
Pancreas Transplant  
Liver Transplant  
Pancreas Transplant  
Rating Stars (Click) RENAL/GENITOURINARY    
Renal Failure  
Renal Surgery  
Renal Transplant  
Arteriovenous Fistula/Shunt  
Nephrostomy Tubes  
Peritoneal Dialysis  
Rating Stars (Click) ENDOCRINE METABOLIC    
Diabetes - Hypo/Hyperglycemic Crisis  
Pituitary Disorders  
IV Insulin Protocols  
Indwelling Insulin Pumps  
Rating Stars (Click) MEDICATIONS    
Anti-Arrhythmics  
Anticoagulants (IV, oral, & injection)  
Anti-Hypertensives  
Anti-Psychotics  
Anti-Seizure Medications  
Benzodiazepines  
Procedural Sedation  
Diuretics  
Emergency Medications  
Inhaled Medications  
Insulin  
Titrate Vasoactive Drips  
Manage Vasoactive Drips - No Titration  
Narcotics/Opioid Analgesics (IV, oral, & injection)  
Nitrates (Oral & Topical)  
Non-Opioid Analgesics (IV, Oral, & Injection)  
Reversal Agents  
Steroids (IV, Oral, Inhaled)  
Automated Medication Dispensing (i.e. Pyxis, Omnicell)  
Rating Stars (Click) IV THERAPY    
Starting Ivs  
Central Line Blood Draws  
Central Line/Implanted Line Care  
Arterial Line Management  
TPN & Lipids  
Blood Product Administration  
Administration of Chemotherapy  
Rating Stars (Click) CARDIAC MONITORING & EMERG. RESPONSE    
Dysrhythmia Interpretation  
Dysrhythmia Management  
Obtain 12 Lead EKG  
Interpret 12 Lead EKG  
Cardioversion  
Defibrillation  
Malignant Hyperthermia  
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS    
National Patient Safety Goals/Core Measures  
Fall Risk Assessment/Prevention  
Pressure Ulcer Risk Assessment/Prevention  
Restraints/Use of Least Restrictive Device  
Patient/Family Teaching  
Age Specific/Population-Based Care  
Isolation Precautions  
Infection Prevention  
Pain Assessment & Management  
Charge Experience  
Interpretation and Communication of Lab Values  
Specialty Beds  
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)  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System          
Computerized Physician Order Entry          
Bar Coding for Medication Administration  
  EMR Conversion
   
CERTIFICATIONS   Expiry Date :  
BLS  
ACLS  
PALS  
PCCN  
CCRN  
Critical Care Course  
Telemetry Certificate/Course  
  Other: Specify  
  Other: Specify