Experience Directions 1 - No Experience (has never done or observed) Please circle a value for each question to 2 - Requires Training (In-Service) - not performed within last 36 months provide us and the interested facilities with 3 - Limited Experience (requires assistance or training) - performed within the last 24 months an assessment of your clinical experience. 4 - Experienced (routinely performs without assistance) - performed within the last 12 months These values confirm your strengths within 5 - Able to Supervise, Precept and Teach - performed within the last 6 months your specialty and assist the facility in the selection process of the healthcare professional.
GENERAL NURSING
Experience
ADMIT & ASSESS PATIENTS
1 2 3 4 5
DISCHARGE TEACHING
1 2 3 4 5
SUPERVISE UNLICENSED PERSONNEL
1 2 3 4 5
VITAL SIGN MONITORING
1 2 3 4 5
PULSE OXIMETRY
1 2 3 4 5
ASSIST WITH CODE / RESUSCITATION
1 2 3 4 5
AUTOMATIC EXTERNAL DEFIBRILLATOR
1 2 3 4 5
PORTABLE EKG MONITOR
1 2 3 4 5
ISOLATION TECHNIQUES
1 2 3 4 5
PAIN ASSESSMENT / MANAGEMENT
1 2 3 4 5
ADVANCE DIRECTIVES
1 2 3 4 5
MEDS / IV THERAPY
Experience
ADMINISTER PO MEDICATIONS
1 2 3 4 5
ADMINISTER IM & SQ MEDS
1 2 3 4 5
PERIPHERAL IV INSERTION
1 2 3 4 5
DISCONTINUE PERIPHERAL IVS
1 2 3 4 5
ADMINISTER IV MEDICATIONS
1 2 3 4 5
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Ambulatory Care Skills Checklist
MEDS / IV THERAPY
Experience
NEEDLE-LESS SYSTEMS
1 2 3 4 5
ACCESS / CARE OF CENTRAL LINES
1 2 3 4 5
ACCESS / CARE OF PORTS
1 2 3 4 5
REMOVAL OF CENTRAL LINES
1 2 3 4 5
ACCESS / CARE OF PICC LINE
1 2 3 4 5
REMOVAL OF PICC LINE
1 2 3 4 5
DRAW BLOOD FOR LAB STUDIES
1 2 3 4 5
CARDIAC
Experience
PERFORM 12-LEAD EKG
1 2 3 4 5
APPLICATION OF HOLTER MONITOR
1 2 3 4 5
EXCISION OF NAIL OR NAIL MATRIX
1 2 3 4 5
DEBRIDEMENT OF FOOT WOUNDS
1 2 3 4 5
PACEMAKER TESTING EQUIPMENT
Experience
ATTACH LEADS TO PACEMAKER MONITOR
1 2 3 4 5
DISTINGUISH TYPE OF PACEMAKER
1 2 3 4 5
COLLECT DATA REGARDING PACEMAKER
1 2 3 4 5
PACEMAKER TELEPHONE SERVICE
1 2 3 4 5
VASCULAR PREOP PREP & TEACHING
Experience
PREOPERATIVE TEACHING
1 2 3 4 5
COORDINATE WORKUP(XRAY,LAB,EKG ETC.)
1 2 3 4 5
COLLECT APPROPRIATE DATA
1 2 3 4 5
PREPARE CHART
1 2 3 4 5
INSTRUCT USE OF INCENTIVE SPIROMETER
1 2 3 4 5
GENERAL SURGERY
Experience
DEBRIDEMENT OF WOUND
1 2 3 4 5
INCISION AND DRAINAGE
1 2 3 4 5
SET-UP / ASSIST SUTURING
1 2 3 4 5
SUTURE REMOVAL
1 2 3 4 5
STAPLE REMOVAL
1 2 3 4 5
DRAIN INSERTION
1 2 3 4 5
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Ambulatory Care Skills Checklist
GENERAL SURGERY
Experience
DRAIN REMOVAL
1 2 3 4 5
MINOR SURGERY
1 2 3 4 5
EVACUATION OF HEMATOMA / SEROMA
1 2 3 4 5
EXCISION OF LESIONS AND MASSES
1 2 3 4 5
APPLICATION OF DRESSINGS
1 2 3 4 5
APPLICATION OF BURN DRESSINGS
1 2 3 4 5
ANOSCOPY
1 2 3 4 5
FLEXIBLE SIGMOIDOSCOPY
1 2 3 4 5
HEMORRHOID BANDING
1 2 3 4 5
USE OF DOPPLER
1 2 3 4 5
USE OF ELECTROSURGICAL CAUTERY
1 2 3 4 5
NEUROLOGY
Experience
ADMINISTRATION OF IMITREX
1 2 3 4 5
ADMINISTRATION OF BETASERONE
1 2 3 4 5
ADMINISTRATION OF COPAXONE
1 2 3 4 5
ADMINISTRATION OF AVONEX
1 2 3 4 5
TENS(TRANSCUTANEOUS ELEC.NERVE STIMULATOR)
1 2 3 4 5
ORTHOPEDIC
Experience
PIN CARE
1 2 3 4 5
REMOVE EXTERNAL FIXATORS W/ PIN
1 2 3 4 5
SCREW-HARDWARE REMOVAL
1 2 3 4 5
INSTRUCT CRUTCH WALKING
1 2 3 4 5
CAST CARE
1 2 3 4 5
APPLY BRACES (WRIST,ANKLE ETC.)
1 2 3 4 5
APPLY IMOBILIZERS (CLAVICLE, KNEE ETC.)
1 2 3 4 5
NEUROSURGERY
Experience
ASSIST WITH LUMBAR PUNCTURE
1 2 3 4 5
ASSIST WITH TRIGEMINAL NERVE BLOCK
1 2 3 4 5
HALO ADJUSTMENT
1 2 3 4 5
HALO REMOVAL
1 2 3 4 5
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Ambulatory Care Skills Checklist
NEUROSURGERY
Experience
BACLOFEN PUMP REFILL & CHECK
1 2 3 4 5
SET UP BACLOFEN PUMP COMPUTER
1 2 3 4 5
PULMONARY
Experience
APPLY OXOGEN
1 2 3 4 5
OBTAIN ARTERIAL BLOOD GASES (ABGS)
1 2 3 4 5
INTERPRET ABGS
1 2 3 4 5
THORACENTESIS
1 2 3 4 5
TRACH CARE / SUCTIONING
1 2 3 4 5
INSTRUCT PATIENT / FAMILY REGARDING
Experience
HOME OXYGEN USE
1 2 3 4 5
METERED DOSE INHALER
1 2 3 4 5
AEROCHAMBER
1 2 3 4 5
FLUTTER VALVE
1 2 3 4 5
PEAK FLOW METER
1 2 3 4 5
THERA POSITIVE EXPIR. PRESSURE THERAPY
1 2 3 4 5
GASTROINTESTINAL
Experience
ASSESS BOWEL SOUNDS
1 2 3 4 5
ASSESS GI DISTRESS / BLEEDING
1 2 3 4 5
INSERTION / MONITORING NG TUBE
1 2 3 4 5
DERM & DERM SURGERY
Experience
SHAVE BIOPSY
1 2 3 4 5
PUNCH BIOPSY
1 2 3 4 5
EXCISIONAL BIOPSY
1 2 3 4 5
SCISSOR BIOPSY
1 2 3 4 5
ELECTRODESICCATION & CURETTAGE (ED&
1 2 3 4 5
EXCISION INSULIN PROVACATIVE TEST (TRIPLE TEST)
1 2 3 4 5
UNNA BOOT
1 2 3 4 5
PATCH TEST
1 2 3 4 5
PHOTOTHERAPY
1 2 3 4 5
DERMABRASION
1 2 3 4 5
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Ambulatory Care Skills Checklist
DERM & DERM SURGERY
Experience
NAIL SURGERY
1 2 3 4 5
IM METHOTREXATE INJECTION
1 2 3 4 5
IM STEROID INJECTION
1 2 3 4 5
MOH'S SURGERY / CHEMO
1 2 3 4 5
MOH'S SURGERY CLOSURE
1 2 3 4 5
FACIALS FOR CLEANSING & EXFOLIATION
1 2 3 4 5
FACIALS WITH EXTRACTIONS
1 2 3 4 5
MICRODERMABRASION
1 2 3 4 5
HAIR REMOVAL WITH LASER
1 2 3 4 5
USE OF EQUIPMENT PER INSTRUCTIONS
Experience
TOTAL BODY UVB UNIT (NARROW BAND)
1 2 3 4 5
TOTAL BODY UVB UNIT (BROAD BAND)
1 2 3 4 5
PORTABLE UVB UNIT
1 2 3 4 5
TOTAL BODY UVA UNIT
1 2 3 4 5
PORTABLE UVA UNIT
1 2 3 4 5
PULSED DYE LASER
1 2 3 4 5
ARGON LASER
1 2 3 4 5
CO2 LASER
1 2 3 4 5
VERSA PULSE LASER
1 2 3 4 5
PLASTICS
Experience
LIPOSUCTION
1 2 3 4 5
BLEPHAROPLASTY / RHYTIDECTOMY
1 2 3 4 5
EXCISION OF LESIONS & MASSES
1 2 3 4 5
LASER PROCEDURES
1 2 3 4 5
NIPPLE RECONSTRUCTION
1 2 3 4 5
TISSUE EXPANSION
1 2 3 4 5
UROLOGY
Experience
STRAIGHT / FOLEY CATH FEMALE
1 2 3 4 5
STRAIGHT / FOLEY CATH MALE
1 2 3 4 5
OBTAIN / INSTRUCT CLEAN CATCH URINE
1 2 3 4 5
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Ambulatory Care Skills Checklist
UROLOGY
Experience
CATHETERIZATION OF UROSTOMY
1 2 3 4 5
CATHETERIZATION OF CHARLESTON POUCH
1 2 3 4 5
UROFLOWMETRY
1 2 3 4 5
SUPRAPUBIC TUBE
1 2 3 4 5
NEPHROSTOMY TUBE
1 2 3 4 5
BLADDER INNIGATION AND/OR INSTILLATION
1 2 3 4 5
CYSTOSCOPY
1 2 3 4 5
STENT REMOVAL
1 2 3 4 5
BLADDER BIOPSY
1 2 3 4 5
CYSTOMETROGRAM
1 2 3 4 5
URETHRAL DILATATION
1 2 3 4 5
CONTIGEN INJECTION TO BLADDER NECK
1 2 3 4 5
TESTOSTERONE IMPLANT
1 2 3 4 5
LUPRON THERAPY FOR PROSTATE CANCER
1 2 3 4 5
CATHETERIZATION OF UROSTOMY
1 2 3 4 5
PAP SMEARS
1 2 3 4 5
ENDOCRINOLOGY
Experience
SPECIALIZED ENDOCRINE TESTS
1 2 3 4 5
THYROID ASPIRATE / BIOPSY
1 2 3 4 5
INSULIN PROVACATIVE TEST (TRIPLE TEST)
1 2 3 4 5
TB SKIN TESTING
1 2 3 4 5
USE OF ACCUCHECK MONITOR
1 2 3 4 5
DIABETIC TEACHING
1 2 3 4 5
EARS, NOSE & THROAT
Experience
SINUS IRRIGATION
1 2 3 4 5
EAR BIPOSY
1 2 3 4 5
EAR IRRIGATION W/ HI PRESSURE SYRINGE
1 2 3 4 5
NOSE BIOPSY
1 2 3 4 5
MOUTH BIOPSY
1 2 3 4 5
MYRINGOTOMY WITH TUBES
1 2 3 4 5
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Ambulatory Care Skills Checklist
EARS, NOSE & THROAT
Experience
MYRINGOTOMY WITHOUT TUBES
1 2 3 4 5
CLOSED REDUCTION OF NASAL FRACTURE
1 2 3 4 5
FIBEROPTIC LARYNGOSCOPY
1 2 3 4 5
FACIAL NERVE MONITOR STIMULATION
1 2 3 4 5
MALONEY ESOPHAGEAL DILATATION
1 2 3 4 5
PAIN MANAGEMENT
Experience
TRIGGER POINT INJECTIONS
1 2 3 4 5
CERVICAL EPIDURAL
1 2 3 4 5
LUMBAR EPIDURAL
1 2 3 4 5
STELLATE GANGLIAN BLOCK
1 2 3 4 5
BIER BLOCK
1 2 3 4 5
AXILLARY BLOCK
1 2 3 4 5
THORACIC EPIDURAL
1 2 3 4 5
LIDOCAINE INFUSION TEST
1 2 3 4 5
IMPLANTABLE NARCOTIC PUMP REFILL
1 2 3 4 5
CAUDAL
1 2 3 4 5
SELECTIVE NERVE ROOT BLOCKS
1 2 3 4 5
FACET JOINT BLOCKS
1 2 3 4 5
CELIAC PLEXUS BLOCKS
1 2 3 4 5
USE OF PNEUMATIC TOURNIQUET
1 2 3 4 5
CRYO-ANALGESIA MACHINE
1 2 3 4 5
MAXILLOFACIAL
Experience
MAXILLOFACIAL PROSTHETICS
1 2 3 4 5
PROSTHODONTICS-RESTORATIVE DENTISTRY
1 2 3 4 5
PREVENTIVE CARE
1 2 3 4 5
STERILIZATION & INFECTION CONTROL
1 2 3 4 5
PATIENT TEACHING - FOLLOW-UP CARE
1 2 3 4 5
RHEUMATOLOGY
Experience
ARTHROCENTESIS (ASPIRATION)
1 2 3 4 5
ARTHROCENTESIS (INJECTION)
1 2 3 4 5
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Ambulatory Care Skills Checklist
RHEUMATOLOGY
Experience
SOLGANOL (GOLD) INJECTION
1 2 3 4 5
TRANSPLANT
Experience
LIVER BIOPSY
1 2 3 4 5
KIDNEY BIPOSY
1 2 3 4 5
PARACENTESIS
1 2 3 4 5
AGE APPROPRIATE CARE
Experience
NEWBORN (BIRTH-30 DAYS)
1 2 3 4 5
INFANT (30 DAYS - 1 YEAR)
1 2 3 4 5
TODDLER (1 - 3 YEARS)
1 2 3 4 5
PRESCHOOLER (3 - 5 YEARS)
1 2 3 4 5
SCHOOL AGE (5 - 12 YEARS)
1 2 3 4 5
ADOLESCENTS (12 - 18 YEARS)
1 2 3 4 5
YOUNG ADULTS (18 - 39 YEARS)
1 2 3 4 5
MIDDLE ADULTS (39 - 64 YEARS)
1 2 3 4 5
OLDER ADULTS (64+ YEARS)
1 2 3 4 5
The information represented above is true and correct to the best of my knowledge. I also authorize Specialty Professional Services, Corp to share the above skills checklist with its facility clients.
