Maxim Physician Resources
Neonatology
Skills Checklist
Enter the appropriate provider code in the blank next to the procedure. Failure to fill this
out correctly can delay the screening process.
Provider Codes
1 Fully competent to perform
2 Competent with supervision
3 Not requested due to lack of expertise
Please check all that apply to your scope of practice.
I.
Practice Setting
___ Nursery Level II / NICU – evaluate and manage sick newborns; ventilator assistance
may or may not be needed; ability to transfer to higher level of care if needed.
___ Nursery Level III / NICU – evaluate and manage sick newborns; ventilator assistance
frequently required; consultation with multiple specialties available; no ability to transfer
to higher level of care, lateral transfer possible for technical requirements.
___ Willing to transport newborns.
II. Specific Procedures
___Ventilation Management
___ Invasive (ETT)
___ Familiarity with use of nitric oxide (iNO)
___ ECMO
___ Chest Tube
___ Evaluation and Management of Acute Volume / BP Issues
Insertion of
___ Central Line
___ Arterial Lind
___ PA Catheter
___ Exchange Transfusions
___ Hemodialysis Catheter Placement
___ Diagnostic/Therapeutic Taps # (including those specified below)
___ Lumbar Puncture
___ Paracentesis
___ Thoracentesis
___ Circumcision
Printed Name: ________________________________________________________________
Signature: _________________________________________________ Date: ____________