Long Term Care Skills Checklist
   LAST 4 OF SSN      
I hereby certify that ALL information I have provided to FILL IN THE BLANK 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  
Use of cardiac monitors  
Assessment of heart sounds  
Cardiac Arrest  
Care of patients with CHF  
Atropine administration  
Digoxin administration  
Dopamine administration  
Inderal administration  
Lidocaine administration  
Rating Stars (Click) GENITOURINARY 1 2 3 4  
Fluid Balance  
Foley Catheter Insertion  
GU Irrigations  
Nephrostomy Tube  
Rating Stars (Click) ENDOCRINE 1 2 3 4  
Blood Glucose Checks  
Insulin Administration  
Care of patients with Diabetes  
Rating Stars (Click) GASTROINTESTINAL 1 2 3 4  
NG tube care and feedings  
Gastrostomy tube care and feedings  
Colostomy Care  
Assessment of Bowel Sounds  
Rating Stars (Click) LEADERSHIP/PATIENT CARE 1 2 3 4  
Taking Charge   
Admission Procedures  
Discharge Procedures  
Patient Education  
Patient Care Plans  
Rating Stars (Click) MEDICATIONS/IV THERAPY 1 2 3 4  
Medication Calculation  
Oral Administration  
Eye Administration  
IM Administration  
SQ Administration  
Rectal Administration  
Starting IV’s  
IV Medication Administration  
Central Line Care  
Rating Stars (Click) NEUROLOGY 1 2 3 4  
Assessment of Neurological Status  
Seizure Precautions  
Care of a patient with a CVA  
Care of a patient with Alzheimer’s  
Care of patients with Spinal Cord Injury  
Decadron Administration  
Dilantin Administration  
Phenobarbital Administration  
Valium Administration  
Rating Stars (Click) ORTHO/SKIN 1 2 3 4  
Assessment of skin  
Wound Care and Treatments  
Use of special pressure relief devices  
Care of pts with a total hip replacement  
Care of pts with a total knee replacement  
Crutch Walking  
Rating Stars (Click) RESPIRATORY 1 2 3 4  
Pulse Oximetry  
Oxygen Administration via nasal cannuia  
Oxygen Administration via face mask  
Principles of chest percussion  
Care of patients with ventilator  
Care of patients with COPD  
Care of patients with ARDS  
Care of patient with a Tracheotomy  
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)