Name: _______________________ Date: ______________________
Med/Surg Skills Assessment Checklist
Please indicate your level of experience
A. Theory, no practice
C. One - two years’ experience
B. Intermittent experience
D. Two plus years’ experience
1. Cardiovascular
a. Assessment
i. Auscultation (rate, rhythm)
ii. Blood pressure/non-invasive
iii. Doppler
iv. Heart sounds/murmurs
v. Pulses/circulation checks
b. Equipment & procedures
i. Telemetry
1. Basic 12 lead interpretation
2. Basic arrhythmia interpretation
3. Lead placement
4. Pacemaker
a. Permanent
b. Temporary
c. Care of the patient with:
i. Abdominal aortic bypass
ii. Aneurysm
iii. Angina
iv. Cardiac arrest
v. Cardiomyopathy
vi. Carotid endarterectomy
vii. Congestive heart failure (CHF)
viii. Femoral-popliteal bypass
ix. Myocarditis
x. Post acute MI (24-48 hours)
xi. Post angioplasty
xii. Post cardiac cath
xiii. Post cardiac surgery
xiv. Thrombophlebitis
d. Medications
i. Heparin drip
ii. Oral anticoagulants
iii. Oral & IVP antihypertensives
iv. Oral & topical nitrates
A
A
A
A
A
B
B
B
B
B
C
C
C
C
C
D
D
D
D
D
A
A
A
B
B
B
C
C
C
D
D
D
A
A
B
B
C
C
D
D
A
A
A
A
A
A
A
A
A
A
A
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A
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B
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B
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C
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C
C
C
C
C
C
C
C
C
C
C
C
D
D
D
D
D
D
D
D
D
D
D
D
D
D
A
A
A
A
B
B
B
B
C
C
C
C
D
D
D
D
~1~
Revised January 4, 2016
Name: _______________________ Date: ______________________
2. Pulmonary
a. Assessment
i. Breath sounds
ii. Rate and work of breathing
b. Interpretation of lab results
i. Blood chemistry
ii. Blood gases
c. Equipment & procedures
i. Airway management devices/suctioning
1. Endotracheal tube/suctioning
2. Nasal airway/suctioning
3. Oropharyngeal/suctioning
4. Sputum specimen collection
5. Tracheostomy/suctioning
ii. Assist with intubation
iii. Assist with thoracentesis
iv. Care of the patient on a ventilator
v. Care of the patient with a chest tube
1. Assist with set-up & insertion
2. Measuring and emptying
3. Removal
vi. Chest physiotherapy
vii. Incentive spirometry
viii. O2 therapy & medication delivery systems
1. Bag and mask
2. External CPAP
3. Face masks
4. Inhalers
5. Nasal cannula
6. Portable O2 tank
7. Trach collar
ix. Oximetry
d. Care of the patient with:
i. Bronchoscopy
ii. COPD
iii. Fresh tracheostomy
iv. Lobectomy
v. Pneumonectomy
vi. Pneumonia
vii. Pulmonary embolism
viii. Thoracotomy
ix. Tuberculosis
A
A
B
B
C
C
D
D
A
A
B
B
C
C
D
D
A
A
A
A
A
A
A
A
B
B
B
B
B
B
B
B
C
C
C
C
C
C
C
C
D
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D
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D
A
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A
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C
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D
D
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D
D
A
A
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B
B
B
B
B
C
C
C
C
C
C
C
C
D
D
D
D
D
D
D
D
A
A
A
A
A
A
A
A
A
B
B
B
B
B
B
B
B
B
C
C
C
C
C
C
C
C
C
D
D
D
D
D
D
D
D
D
~2~
Revised January 4, 2016
Name: _______________________ Date: ______________________
3. Neurological
a. Assessment
i. Glasgow coma scale
ii. Level of consciousness
b. Equipment & procedures
i. Assist with lumbar puncture
ii. Use of hyper/hypothermia blanket
c. Care of the patient with:
i. Aneurysm precautions
ii. Basal skull fractures
iii. Closed head injury
iv. Coma
v. CVA
vi. DTs
vii. Encephalitis
viii. Externalized VP shunts
ix. Meningitis
x. Neuromuscular disease
xi. Post craniotomy
xii. Seizures
xiii. Spinal cord injury
d. Administration of anticonvulsants
4. Orthopedics
a. Assessment
i. Circulation checks
ii. Gait
iii. Range of motion
iv. Skin
b. Equipment & procedures
i. Continuous passive motion devices
ii. Support devices
1. Cane
2. Cervical collar
3. Gait belt
4. Prosthetic
5. Sling
6. Transfer boards
7. Walker
8. Wheelchair
9. Traction
c. Care of the patient with:
A
A
B
B
C
C
D
D
A
A
B
B
C
C
D
D
A
A
A
A
A
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A
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A
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D
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D
D
D
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D
A
A
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B
C
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C
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D
D
D
D
A
B
C
D
A
A
A
A
A
A
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A
A
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B
B
B
B
B
B
B
B
C
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C
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C
D
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D
D
D
D
D
D
D
~3~
Revised January 4, 2016
Name: _______________________ Date: ______________________
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
Amputation
Arthroscopic surgery
Cast
Osteoporosis
Pinned fractures
Rheumatic/arthritic disease
Total hip replacement
Total knee replacement
5. Gastrointestinal
a. Assessment
i. Abdominal/bowel sounds
ii. Fluid balance
iii. Nutritional
b. Interpretation of blood chemistry
c. Equipment & procedures
i. Administration of tube feeding
1. Feeding pump
2. Gravity feeding
3. Saline lavage
4. Flexible feeding tube
ii. Management of
1. Gastrostomy tube
2. Jejunostomy tube
3. T-tube
iii. Placement of nasogastric tube
iv. Salem sump to suction
d. Care of the patient with:
i. Bowel obstruction
ii. Colostomy/ileostomy
iii. GI bleeding
iv. GI surgery
v. Hepatitis
vi. Inflammatory bowel disease
vii. Invasive diagnostic testing
viii. Liver failure
ix. Paralytic ileus
6. Renal/Genitourinary
a. Assessment
i. Arterio venous fistula/shunt
ii. Fluid balance
iii. Interpretation of lab results
A
A
A
A
A
A
A
A
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B
B
B
B
B
B
C
C
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C
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C
C
D
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D
A
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A
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D
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A
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C
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D
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D
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D
A
A
B
B
C
C
D
D
~4~
Revised January 4, 2016
Name: _______________________ Date: ______________________
1. BUN & creatinine
2. Electrolytes
b. Equipment & procedures
i. Insertion & care of straight and Foley catheter
1. Female
2. Male
ii. Catheter care
1. 3-way Foley
2. Supra-pubic
iii. Bladder irrigations
1. Continuous
2. Intermittent
iv. Specimen collection
1. Routine
2. 24 hours
c. Care of the patient with:
i. Hemodialysis
ii. Nephrectomy
iii. Peritoneal dialysis
iv. Renal failure
v. Renal transplant
vi. TURP
vii. Urinary diversion/ileal conduit nephrostomy
viii. Urinary tract infection
7. Endocrine/Metabolic
a. Assessment
i. S/S diabetic coma
ii. S/S insulin reaction
b. Equipment & procedures
i. Blood glucose monitoring
1. Electronic measuring device: type
2. Performing finger stick
3. Visual blood glucose strips
ii. Indwelling insulin pump
c. Care of the patient with:
i. Diabetes mellitus
ii. Disorders of adrenal gland
iii. Disorders of pituitary gland
iv. Hyperthyroidism (Grave's disease)
v. Hypothyroidism
vi. Thyroidectomy
d. Medications (administration and teaching)
A
A
B
B
C
C
D
D
A
A
B
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C
C
D
D
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D
D
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D
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D
D
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C
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D
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A
A
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D
D
_____________________
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D
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D
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D
~5~
Revised January 4, 2016
Name: _______________________ Date: ______________________
i.
ii.
iii.
iv.
Insulin
Oral hypoglycemics
Steroids
Thyroid
8. Wound Management
a. Assessment
i. Skin for impending breakdown
ii. Stasis ulcers
iii. Surgical wound healing
b. Equipment & procedures
i. Air fluidized, low air loss beds
ii. Sterile dressing changes
iii. Wound care/irrigations
c. Care of the patient with:
i. Burns
ii. Pressure sores
iii. Staged decubitus ulcers
iv. Surgical wounds with drain(s)
v. Traumatic wounds
9. Oncology
a. Assessment
i. Nutritional status
ii. Pain control
b. Interpretation of lab results
i. Blood chemistry
ii. Blood counts
c. Equipment & procedures
i. Reverse isolation
d. Care of the patient with:
i. Bone marrow transplant
ii. Fresh oncologic surgery
iii. Inpatient chemotherapy
iv. Inpatient hospice
v. Leukemia
vi. Radiation implant
e. Medications:
i. Chemotherapy certification?
10. Infectious Diseases
a. Interpretation of lab results:
i. Blood count
b. Equipment & procedures
A
A
A
A
B
B
B
B
C
C
C
C
D
D
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D
A
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D
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D
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D
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A
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B
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D
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D
D
D
D
C
D
Yes
A
No
B
~6~
Revised January 4, 2016
Name: _______________________ Date: ______________________
i. Fever management
ii. Isolation
c. Care of the patient with:
i. AIDS
ii. Hepatitis
iii. Lyme disease
11. Phlebotomy/IV Therapy
a. Equipment & procedures
i. Administration of blood/blood products
1. Albumin
2. Cryoprecipitate
3. Packed red blood cells
4. Plasma
5. Whole blood
ii. Drawing blood from central line
iii. Drawing venous blood
iv. Starting IVs
1. Angiocath
2. Butterfly
3. Heparin lock
b. Care of the patient with:
i. Central line/catheter/dressing
1. Broviac
2. Groshong
3. Hickman
4. Portacath
5. Quinton
ii. Peripheral line/dressing
12. Pain Management
a. Assessment of pain level/tolerance
b. Care of the patient with:
i. Epidural anesthesia/analgesia
ii. IV conscious sedation
iii. Patient controlled analgesia (PCA pump)
A
A
B
B
C
C
D
D
A
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C
D
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D
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A
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D
D
Certification:
Please read and agree to the statements below by signing and dating the bottom of this form.
I attest that the information I have given is true and accurate to the best of my knowledge and
that I am the individual completing this form. I hereby authorize Simply The Best Healthcare
~7~
Revised January 4, 2016
Name: _______________________ Date: ______________________
Staffing to release this Skills Checklist to the Client facilities in relation to consideration of
employment with those facilities.
Signature: ___________________________ Date: __________________________
~8~
Revised January 4, 2016