LAST 4 OF SSN      
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) Administrative Duties 1 2 3 4  
Data Entry  
Medical Records - Entry  
Medical Records - Maintenance  
Electronic Medical Records - Entry  
Electronic Medical Records - Maintenance  
Gathers data and runs reports  
Patient Files - Set up, report and record  
Completion and filing/distribution of reports  
Schedules appointments/tests  
Takes, distributes and prioritizes messages  
Assists physicians with procedures  
Assists nursing staff  
Prepares patients for appointments and exams  
Gathers patient history and VS  
Gives injections as directed  
Performs phlebotomy skills  
Collects lab. Specimens  
Administer EKGs  
Completes specimen testing, i.e. glucose, strep, mono, flu  
Prepares and maintains supplies and equipment  
Knows utilization of patient care equipment/instruments  
Develops patient, physician and peer relationships  
Maintains/protects patient confidentiality  
Adheres to facility policies and procedures  
Adheres to OSHA, HIPPA, legal and ethical guidelines  
Adheres to quality protocol and standards  
Attends and participates in required meetings  
Schedules appointments, tests and treatments  
Responds to emergencies in a calm organized manner  
Understands/follows the reporting process acording to the chain of command  
Rating Stars (Click) Computer Skills: 1 2 3 4  
Medic, Medic Soft  
Medical Manager  
Word, Word Perfect  
Rating Stars (Click) AGE SPECIFIC COMPETENCIES 1 2 3 4  
Newborn (birth to 30 days)  
Infant (31 days to 1 year)  
Toddler (ages 2-3 years)  
Preschooler (ages 4-5 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)