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Nurse Practitioner Skills Checklist | ||||||
| NAME | |||||||
| LAST 4 OF SSN | |||||||
| DATE | |||||||
| 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 |
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| Rating Stars (Click) | Areas Worked | 1 | 2 | 3 | 4 | ||
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Emergency | ||||||
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Urgent Care | ||||||
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Private Practice | ||||||
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HMO | ||||||
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MD Office | ||||||
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Schools | ||||||
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Health Department | ||||||
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Ambulatory Clinic | ||||||
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Rural Health Clinic | ||||||
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Psychiatric Facility | ||||||
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Correctional Facility | ||||||
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Mobile Medical Unit | ||||||
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Corporate Worksite | ||||||
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Occupational Health | ||||||
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Rehabilitation | ||||||
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Nursing Home/ Long-term Care Facility | ||||||
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Women's Health Clinic | ||||||
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Government Health Agency | ||||||
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Hospice/Palliative Care | ||||||
| Rating Stars (Click) | Experience With | 1 | 2 | 3 | 4 | ||
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Diabetes | ||||||
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Contractures | ||||||
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Bedridden residents | ||||||
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Splinting of extremities | ||||||
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Local infiltration | ||||||
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Comprehensive physical assessment | ||||||
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Acute disease condition | ||||||
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Differential diagnosis | ||||||
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Order, may perform, & interpret screening & diagnostic test | ||||||
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Central line management | ||||||
| Rating Stars (Click) | Disorders – Emergencies | 1 | 2 | 3 | 4 | ||
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Anaphylaxis | ||||||
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Cardiac arrest | ||||||
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Seizures | ||||||
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Minor head injuries | ||||||
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Animal bites | ||||||
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Ingestions and poisonings | ||||||
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Overdose of sedative, hypnotics, opiates | ||||||
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Snake bites | ||||||
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Minor burns | ||||||
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Shock | ||||||
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Open wounds | ||||||
| Rating Stars (Click) | Collaboration | 1 | 2 | 3 | 4 | ||
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Family, support system, community resources | ||||||
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Consulting with Physicians | ||||||
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Consulting with Pharmacists | ||||||
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Consulting with Speech Therapist | ||||||
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Consulting with Dietician and Diet Aide | ||||||
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Consulting with Occupational Therapist | ||||||
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Referral to Pastoral Services | ||||||
| Rating Stars (Click) | Respiratory | 1 | 2 | 3 | 4 | ||
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Croup | ||||||
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Influenza | ||||||
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Tracheobronchitis | ||||||
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Bronchitis | ||||||
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COPD (chronic obstructive pulmonary disease) | ||||||
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Asthma | ||||||
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URI (upper respiratory infection) | ||||||
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Obstructive Sleep Apnea | ||||||
| Pneumonia: | |||||||
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Viral | ||||||
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Bacterial | ||||||
| Sinusitis: | |||||||
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Bacterial | ||||||
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Nonbacteria | ||||||
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Oxygen administration | ||||||
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Liquid oxygen | ||||||
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IPPB machine use | ||||||
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Tracheotomies | ||||||
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Interpret ABG (blood gases) | ||||||
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Intubations | ||||||
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Sputum Collection | ||||||
| Rating Stars (Click) | Cardiovascular System | 1 | 2 | 3 | 4 | ||
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Congestive heart failure | ||||||
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Chronic obstructive pulmonary disease | ||||||
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Stasis ulcer of lower extremities | ||||||
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Angina | ||||||
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Pericarditis | ||||||
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Coronary artery disease | ||||||
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Functional murmurs | ||||||
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Congenital heart disease | ||||||
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Hypertension | ||||||
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ASHD (arteriosclerotic heart disease) | ||||||
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Dyslipidemia | ||||||
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PVD (peripheral vascular disease) | ||||||
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Peripheral neuropathy | ||||||
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Interpreting 12 lead EKG’s | ||||||
| Rating Stars (Click) | OB/GYN | 1 | 2 | 3 | 4 | ||
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Candida vaginitis | ||||||
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Dysmenorrhea | ||||||
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Abnormal pap smear findings | ||||||
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Pap smears | ||||||
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Trichomonal vaginitis | ||||||
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Atrophic vaginitis | ||||||
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Fibrocystic breast disease | ||||||
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Menopause | ||||||
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Intrapartum medications | ||||||
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Bartholin's cyst/abscess | ||||||
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Preparation for childbirth | ||||||
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Pregnancy - diagnosis and referral | ||||||
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Pain relief in active phase of labor | ||||||
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Medications in the third stage | ||||||
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Dysfunctional uterine bleeding | ||||||
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Medications in the postpartum phase | ||||||
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Rh blood factor | ||||||
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Mastitis | ||||||
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Birth control methods | ||||||
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Prenatal care | ||||||
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Fetal well-being | ||||||
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Nausea and vomiting with pregnancy | ||||||
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Pap smears | ||||||
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Pregnancy test kits | ||||||
| Rating Stars (Click) | GI System | 1 | 2 | 3 | 4 | ||
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Constipation | ||||||
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Diarrhea (simple) | ||||||
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Acute gastroenteritis | ||||||
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Cholecystitis | ||||||
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Pyloric stenosis | ||||||
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Colic | ||||||
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Appendicitis | ||||||
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Naso-gastric tubes | ||||||
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Gastrostomy Care | ||||||
| Rating Stars (Click) | Skin | 1 | 2 | 3 | 4 | ||
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Warts | ||||||
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Basal cell carcinoma | ||||||
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Scabies | ||||||
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Impetigo | ||||||
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Diaper dermatitis | ||||||
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Acne | ||||||
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Folliculitis | ||||||
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Furuncles | ||||||
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Carbuncles | ||||||
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Herpes Simplex | ||||||
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Herpes Zoster | ||||||
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Malignant melanoma | ||||||
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Pityriasis Rosea | ||||||
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Contact dermatitis | ||||||
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Tinea corporis | ||||||
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Tinea pedis | ||||||
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Staph infections | ||||||
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Wound care | ||||||
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Single layer wound closure | ||||||
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Incision and drainage | ||||||
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Excisions | ||||||
| Rating Stars (Click) | Ears, Nose and Throat | 1 | 2 | 3 | 4 | ||
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Epistaxis | ||||||
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Otitis externa | ||||||
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Serous otitis media | ||||||
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Acute purulent otitis media | ||||||
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Allergic rhinitis | ||||||
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Pharyngitis | ||||||
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Oral candidiasis | ||||||
| Rating Stars (Click) | Eye | 1 | 2 | 3 | 4 | ||
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Conjunctivitis | ||||||
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Strabismus | ||||||
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Chalazion | ||||||
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Stye | ||||||
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Visual acuity | ||||||
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Fluorescein staining of eyes | ||||||
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Audiometry | ||||||
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Tympanometry | ||||||
| Rating Stars (Click) | Musculoskeletal | 1 | 2 | 3 | 4 | ||
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Osteoporosis | ||||||
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Osteomyelitis | ||||||
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Rheumatoid arthritis | ||||||
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Juvenile diabetes | ||||||
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Gout | ||||||
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Minor sprains and strains | ||||||
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Osteoarthritis | ||||||
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Carpal tunnel syndrome | ||||||
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Scoliosis | ||||||
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Tendonitis | ||||||
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Bursitis | ||||||
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Muscular dystrophy | ||||||
| Rating Stars (Click) | Parasitic Infections | 1 | 2 | 3 | 4 | ||
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Pinworms | ||||||
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Ascariasis | ||||||
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Pediculosis | ||||||
| Rating Stars (Click) | Genitourinary System | 1 | 2 | 3 | 4 | ||
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Syphilis | ||||||
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Chlamydia | ||||||
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Herpes | ||||||
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Cystitis | ||||||
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Pyelonephritis | ||||||
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Urinary tract infection | ||||||
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Benign prostatic hypertrophy | ||||||
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Vulvovaginitis | ||||||
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Hypospadias | ||||||
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Hydrocele | ||||||
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Gonococcal infections | ||||||
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Prostatitis | ||||||
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Catheter Care | ||||||
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Incontinence care-bowel | ||||||
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Dermal ulcers | ||||||
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Enemas/ Suppositories/ Fecal | ||||||
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Urine collection | ||||||
| Rating Stars (Click) | Nervous System | 1 | 2 | 3 | 4 | ||
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Vasovagal syncope | ||||||
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Migraine headaches | ||||||
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Multiple sclerosis | ||||||
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Headaches | ||||||
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Head injury | ||||||
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Tension | ||||||
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Anxiety | ||||||
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Parkinson’s | ||||||
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Alzheimer’s | ||||||
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Bell’s Palsy | ||||||
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TIA (transient ischemic attacks) | ||||||
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Trigeminal neuralgia | ||||||
| Rating Stars (Click) | Endocrine | 1 | 2 | 3 | 4 | ||
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Type I diabetes mellitus | ||||||
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Type II diabetes mellitus | ||||||
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Graves disease | ||||||
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Addison's disease | ||||||
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Juvenile diabetes | ||||||
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Hypoglycemia | ||||||
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Hypothyroidism | ||||||
| Rating Stars (Click) | Hematological | 1 | 2 | 3 | 4 | ||
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Folic acid deficiency anemia | ||||||
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Aplastic anemia | ||||||
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Iron deficiency | ||||||
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Sickle cell anemia | ||||||
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Pernicious anemia | ||||||
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Hemoglobinmeter | ||||||
| Rating Stars (Click) | Psychosocial | 1 | 2 | 3 | 4 | ||
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Depression | ||||||
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Suicide | ||||||
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Obesity | ||||||
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Grief | ||||||
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Anxiety | ||||||
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Anorexia | ||||||
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Bulimia | ||||||
| Rating Stars (Click) | Drug Therapy | 1 | 2 | 3 | 4 | ||
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Prescription | ||||||
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Over the counter (OTC) | ||||||
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Herbal drugs | ||||||
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Knowledge of pharmacology | ||||||
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Knowledge of pharmacokinetics | ||||||
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Knowledge of drug interactions | ||||||
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Knowledge of side effects | ||||||
| Knowledge of potential adverse reactions: | |||||||
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Allergic reactions | ||||||
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Anaphylaxis reaction | ||||||
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TPN/Lipid Management | ||||||
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Management/Titration of IV Therapies | ||||||
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IV/PO Antibiotic Therapy and understanding of cultures | ||||||
| Rating Stars (Click) | Dispensing Medication | 1 | 2 | 3 | 4 | ||
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Monitoring drug therapy | ||||||
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Management of controlled substances | ||||||
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Injections | ||||||
| Rating Stars (Click) | Non-Pharmacologic Interventions | 1 | 2 | 3 | 4 | ||
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Medical nutrition therapy | ||||||
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Exercise | ||||||
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Cessation of substance abuse (alcohol, tobacco) | ||||||
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Mental health issues (stress management, depression) | ||||||
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Obesity management | ||||||
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Tube Feeding Management | ||||||
| Rating Stars (Click) | Miscellaneous | 1 | 2 | 3 | 4 | ||
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Public health and health promotion | ||||||
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Research | ||||||
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Quality assurance | ||||||
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Leadership and teaching skills | ||||||
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Legal and ethical issues | ||||||
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Confidentiality | ||||||
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Cultural awareness | ||||||
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Self evaluation to improve patient care | ||||||
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Continuing education | ||||||
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Working within scope of practice | ||||||
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Discharge planning / collaboration | ||||||
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Suturing | ||||||
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Cell biopsy | ||||||
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Starting IV | ||||||
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Casting and splinting | ||||||
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Radiographic interpretation (initial) | ||||||
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Informed consent | ||||||
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Explanation to patient/family | ||||||
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Documentation | ||||||
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Venipuncture | ||||||
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Ultrasounds | ||||||
| Rating Stars (Click) | Programs | 1 | 2 | 3 | 4 | ||
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OSHA (Occupational Safety and Health Administration) | ||||||
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Medicare and Medicaid | ||||||
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CLIA waiver (Clinical Laboratory Improvement Amendments) | ||||||
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TJC (The Joint Commission) | ||||||
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HEDIS (Health Plan Employer Data and Information Set) | ||||||
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DQIP (Diabetes Quality Improvement Program) | ||||||
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HIPAA (Health Insurance Portability & Accountability Act) | ||||||
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HCAHPS | ||||||
| Rating Stars (Click) | Age Specific Competencies | 1 | 2 | 3 | 4 | ||
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Newborn/neonate (birth-30 days) | ||||||
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Infant (31 days-1 year) | ||||||
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Toddler (ages 2-3 years) | ||||||
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Preschool (ages 4-5 years) | ||||||
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School age (ages 6-12 years) | ||||||
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Adolescents (ages 13-21 years) | ||||||
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Young adult (ages 22-39 years) | ||||||
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Adults (ages 40-64 years) | ||||||
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Older adult (ages 65-79 years) | ||||||
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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 | |||||||