Skills/Experience Checklist Registered Nurse This form is a self-assessment of your current skills and abilities upon initial application. This form is also used to document skill demonstration. EMPLOYEE PROFILE Last Name First Name Middle Initial Employee Number Direct Supervisor (Name) Date Form Initiated RN CPR Card – expiration date The instructions will guide you in completing this form. Previous Experience (Sections Clinical Associate Must Complete) Instruction, Review, or Skill Demonstration (Sections Supervisor or Preceptor Must Complete) Place an X in the appropriate column using the key below KEY A = I am competent to supervise this skill B = I am competent to perform this skill without supervision C = I need to review this skill D = I need additional instruction on this skill E = I have not performed this Supervisor: Indicates whether or not a review of policies/procedures or instruction is required then document completion in the appropriate columns. If C or D is selected, review the instruction and possibly the skills demonstration is required prior to assignment to applicable patients. Preceptor: Documents completion of skills demonstration or indicates NA as applicable. A date and initials in the Skill Demonstration column indicates competency has been achieved. Do not date or initial until competency is achieved. An additional column is provided for repeat demonstrations. Complete the signature section at the end of this form. All RNs must demonstrate competencies for items in bold text and marked with an asterisk (*) prior to the first assignment requiring those skills. Previous Experience Instruction, Review, or Demonstration Required for all RNs A B C D E Review of Needed (Y/N/NA) Review of Instruction Complete Date / Initials Skill Demo Needed (Y/NA) Competency Demonstration Date / Initials For Repeat Skills Demo / Competency Date / Initials * Bag Technique * Hand Hygiene *Aseptic Technique *Sterile Technique *Venous Blood Draws *Wound Vac Therapy Visit documentation Medication reconciliation Care coordination Development of physician orders OASIS completion Discharge/transfer/progress summaries Nursing plan of care development Case Management
Other: State specific requirements: Supervisor/Preceptor Comments: Previous Experience Instruction, Review, or Skill Demonstration Dressing and Care (Required) A B C D E Review of Needed Review of Complete Done Date and Initials Competency For Repeat Skills Date and Initials Competency Wound assessment and documentation Pressure staging Suture removal Staple removal *Clean dressings Advanced dressings Surgical/wound drains and collection devices Wound care teaching State specific requirements: Supervisor/Preceptor Comments: Previous Experience Instruction, Review, or Demonstration Cardiopulmonary Care (Required) A B C D E Review of Needed Review of Complete Skill Done Date and Initials Competency For Repeat Skills Date and Initials Competency Respiratory assessment Cardiac assessment retention (edema) assessment Pulse Ox (O2 saturation) Humidification/heating devices Administration of oxygen
Supervisor/Preceptor Comments: Previous Experience Instruction, Review, or Skill Demonstration Endocrine (Required) A B C D E Review of Needed Review of Complete Skill Done Date and Initials Competency For Repeat Skills Date and Initials Competency Diabetic management and teaching Insulin injection teaching Insulin pump management and teaching Diabetic skin/foot/nail care and teaching Hyper/hypoglycemia S/S teaching (parameters, if applicable) Teaching blood glucose monitoring Other: State specific requirements: Supervisor/Preceptor Comments: Previous Experience Instruction, Review, or Skill Demonstration Medication Administration (Required) A B C D E Review of Needed Review of Complete Skill Done Date and Initials Competency For Repeat Skills Date and Initials Competency Intradermal Subcutaneous Intramuscular Intravenous Inhalation Oral G, J or NG tube Teaching medication administration specific requirements:
Supervisor/Preceptor Comments: Previous Experience Instruction, Review, or Skill Demonstration Pain Management (Required) A B C D E Review of Needed Review of Complete Skill Done Date and Initials Competency For Repeat Skills Date and Initials Competency Assessment and documentation of pain using pain scale Utilization of pain relief medications Utilization of hot/cold therapies Teaching pain management techniques Other: State specific requirements: Supervisor/Preceptor Comments: Previous Experience Instruction, Review, or Skill Demonstration Laboratory Testing (Required) A B C D E Review of Needed Review of Complete Done Date and Initials Competency For Repeat Skills Date and Initials Competency culture and sensitivity Collection of urine samples *CLIA - Fingerstick sugars Equipment: *CLIA - Fingerstick PT INRs Equipment: *Heel Other: specific requirements:
*Dressing changes IV PUMPS *Pump type: *Pump type: *Pump type: Previous Experience Instruction, Review, or Skill Demonstration Infusion Therapy (continued) (complete if applicable) A B C D E Review of Needed Review of Complete Skill Done Date and Initials Competency For Repeat Skills Date and Initials Competency MEDICATIONS *Chemotherapy *Flolan TPN *Amphotericin *Inotropics *Continuous subcutaneous administration State specific requirements: Supervisor/Preceptor Comments: Previous Experience Instruction, Review, or Skill Demonstration Fall Prevention Management A B C D E Review of Needed Review of Complete Done Date and Initials Competency For Repeat Skills Date and Initials Competency Assessment and documentation of fall risk using a screening tool Teaching fall prevention strategies Other: State specific requirements: Supervisor/Preceptor Comments
Previous Experience Instruction, Review, or Skill Demonstration Pediatric Procedures (complete if applicable) A B C D E Review of Needed Review of Complete Skill Done Date and Initials Competency For Repeat Skills Date and Initials Competency Nutritional assessment PO feeding premature infant Feeding infant with cleft lip/palate Intradermal medication administration Subcutaneous medication administration Intramuscular medication administration Medication administration management Use of phototherapy equipment: Case Lights Bili lights Overhead *Tracheostomy care and change *Ventilator care, type: State specific requirements: Supervisor/Preceptor Comments: Previous Experience Instruction, Review, or Skill Demonstration Equipment/ Location Specific Items (complete if applicable) A B C D E Review of Needed Review of Complete Skill Done Date and Initials Competency For Repeat Skills Date and Initials Competency Fetal monitor Apnea monitor Chest physiotherapy Other: specifics: Supervisor/Preceptor Comments: Initials Print Name Signature Title Date (m/d/yyyy)