* = Required Information
Name
*
Proficiency
[1]None
[2]Intermittent
[3]Experienced
Supervise/Teach
Frequency
[1]Observed Only
[2]Less than 6 times/year
[3]Twice a Month
[4]Daily-Weekly
Assessment/Patient Care
General
Proficiency
Frequency
Admission
1
2
3
4
1
2
3
4
Advance Directives
1
2
3
4
1
2
3
4
Collect Appropriate Data
1
2
3
4
1
2
3
4
Discharge Teaching
1
2
3
4
1
2
3
4
Patient and Family Teaching
1
2
3
4
1
2
3
4
Computerized Documentation
Meditech
1
2
3
4
1
2
3
4
CareManager
1
2
3
4
1
2
3
4
Clinivision
1
2
3
4
1
2
3
4
Cerner
1
2
3
4
1
2
3
4
Epic
1
2
3
4
1
2
3
4
Other
1
2
3
4
1
2
3
4
Cardiovascular
General
Auscultation (Rate, Rhythm)
1
2
3
4
1
2
3
4
Pulses/Circulation Checks
1
2
3
4
1
2
3
4
Apical Pulse
1
2
3
4
1
2
3
4
Capillary Refill
1
2
3
4
1
2
3
4
Color
1
2
3
4
1
2
3
4
Patient Experience
Abdominal Aortic Aneurysm
1
2
3
4
1
2
3
4
Acute MI
1
2
3
4
1
2
3
4
Angina
1
2
3
4
1
2
3
4
Cardiac Arrest/CPR
1
2
3
4
1
2
3
4
Cardiomyopathy
1
2
3
4
1
2
3
4
Cardiopulmonary Arrest
1
2
3
4
1
2
3
4
Carotid Endarterectomy
1
2
3
4
1
2
3
4
Congestive_Heart_Failure
1
2
3
4
1
2
3
4
Femoral Popliteal Bypass
1
2
3
4
1
2
3
4
Heart Transplant Hypertension
1
2
3
4
1
2
3
4
Infective Endocarditis
1
2
3
4
1
2
3
4
Myocardial Contusion
1
2
3
4
1
2
3
4
Pacemaker Permanent
1
2
3
4
1
2
3
4
Pericarditis
1
2
3
4
1
2
3
4
AICD
1
2
3
4
1
2
3
4
Hypovolemic Shock
1
2
3
4
1
2
3
4
Monitoring
Vital Sign Monitoring
1
2
3
4
1
2
3
4
EKG Monitoring
1
2
3
4
1
2
3
4
Arrhythmia Interpretation
1
2
3
4
1
2
3
4
Labs
Cardiac Enzymes & Isoenzymes
1
2
3
4
1
2
3
4
Coagulation Studies
1
2
3
4
1
2
3
4
BNP
1
2
3
4
1
2
3
4
Troponin
1
2
3
4
1
2
3
4
Pulmonary
General
Assess Lung Sounds
1
2
3
4
1
2
3
4
Adventitious Breath Sounds
1
2
3
4
1
2
3
4
Rate and Work of Breathing
1
2
3
4
1
2
3
4
Respiratory Assessment
1
2
3
4
1
2
3
4
Oxygenation Status
1
2
3
4
1
2
3
4
Patient Experience
Acute Pneumonia
1
2
3
4
1
2
3
4
Asthma
1
2
3
4
1
2
3
4
COPD
1
2
3
4
1
2
3
4
Cor Pulmonale
1
2
3
4
1
2
3
4
Lobectomy
1
2
3
4
1
2
3
4
Lung Transplant
1
2
3
4
1
2
3
4
Pneumonectomy
1
2
3
4
1
2
3
4
Pulmonary Edema
1
2
3
4
1
2
3
4
Pulmonary Embolism
1
2
3
4
1
2
3
4
Tracheostomy
1
2
3
4
1
2
3
4
Tuberculosis
1
2
3
4
1
2
3
4
Monitoring
Pulse Oximetry
1
2
3
4
1
2
3
4
Neurological
General
Glasgow Coma Scale
1
2
3
4
1
2
3
4
Level of Consciousness
1
2
3
4
1
2
3
4
Neurological Assessment
1
2
3
4
1
2
3
4
Reflex/motor Deficits
1
2
3
4
1
2
3
4
Visual or Communication Deficits
1
2
3
4
1
2
3
4
Patient Experience
Alzheimer's Disease
1
2
3
4
1
2
3
4
Coma
1
2
3
4
1
2
3
4
CVA
1
2
3
4
1
2
3
4
DTs
1
2
3
4
1
2
3
4
Intracranial Hemorrhage
1
2
3
4
1
2
3
4
Laminectomy
1
2
3
4
1
2
3
4
Meningitis
1
2
3
4
1
2
3
4
Metastatic Tumor
1
2
3
4
1
2
3
4
Multiple Sclerosis
1
2
3
4
1
2
3
4
Neuromuscular Disease
1
2
3
4
1
2
3
4
Post Craniotomy
1
2
3
4
1
2
3
4
Seizure Disorder
1
2
3
4
1
2
3
4
Spinal Cord Injury
1
2
3
4
1
2
3
4
Gastrointestinal
General
Bowel Sounds
1
2
3
4
1
2
3
4
Nutritional Status
1
2
3
4
1
2
3
4
G.I. Assessment
1
2
3
4
1
2
3
4
Colostomy Care
1
2
3
4
1
2
3
4
Patient Experience
Abdominal Wounds and Surgeries
1
2
3
4
1
2
3
4
Blunt Trauma
1
2
3
4
1
2
3
4
Bowel Obstruction
1
2
3
4
1
2
3
4
Colostomy
1
2
3
4
1
2
3
4
Esophageal Bleeding
1
2
3
4
1
2
3
4
GI Bleeding
1
2
3
4
1
2
3
4
GI Surgery
1
2
3
4
1
2
3
4
Hepatitis
1
2
3
4
1
2
3
4
Ileostomy
1
2
3
4
1
2
3
4
Inflammatory Bowel Disease
1
2
3
4
1
2
3
4
Liver Failure
1
2
3
4
1
2
3
4
Liver Transplant
1
2
3
4
1
2
3
4
Pancreatitis
1
2
3
4
1
2
3
4
Paralytic Ileus
1
2
3
4
1
2
3
4
Jejunostomy Tube
1
2
3
4
1
2
3
4
Liver Cancer
1
2
3
4
1
2
3
4
Pancreatic Cancer
1
2
3
4
1
2
3
4
Labs
LFTs
1
2
3
4
1
2
3
4
Serum Ammonia
1
2
3
4
1
2
3
4
Serum Amylase
1
2
3
4
1
2
3
4
Renal/Genitourinary
General
Skin Turgor
1
2
3
4
1
2
3
4
Fluid Status
1
2
3
4
1
2
3
4
Patient Experience
Acute Renal Failure
1
2
3
4
1
2
3
4
BPH
1
2
3
4
1
2
3
4
Bladder Irrigation
1
2
3
4
1
2
3
4
End Stage Renal Disease
1
2
3
4
1
2
3
4
Hemodialysis
1
2
3
4
1
2
3
4
Ileal Conduit
1
2
3
4
1
2
3
4
Nephrectomy
1
2
3
4
1
2
3
4
Nephrostomy Tube
1
2
3
4
1
2
3
4
Peritoneal Dialysis
1
2
3
4
1
2
3
4
Renal Transplant
1
2
3
4
1
2
3
4
Urinary Diversion
1
2
3
4
1
2
3
4
Urinary Tract Infection
1
2
3
4
1
2
3
4
Suprapubic Cath
1
2
3
4
1
2
3
4
Fistula/Shunt
1
2
3
4
1
2
3
4
Monitoring
Measurement of I & O
1
2
3
4
1
2
3
4
Fluid Balance
1
2
3
4
1
2
3
4
Labs
BUN & Creatinine
1
2
3
4
1
2
3
4
Serum Electrolytes
1
2
3
4
1
2
3
4
Endocrine/Metabolic
Patient Experience
Diabetics
1
2
3
4
1
2
3
4
Diabetic Ketoacidosis
1
2
3
4
1
2
3
4
Drug Overdose
1
2
3
4
1
2
3
4
Labs
Blood Glucose
1
2
3
4
1
2
3
4
Thyroid Studies
1
2
3
4
1
2
3
4
General
Circulation Checks
1
2
3
4
1
2
3
4
Cast Care
1
2
3
4
1
2
3
4
Crutch Walking
1
2
3
4
1
2
3
4
Patient Experience
Amputation
1
2
3
4
1
2
3
4
External Fixation
1
2
3
4
1
2
3
4
Multiple Trauma
1
2
3
4
1
2
3
4
Paraplegia
1
2
3
4
1
2
3
4
Post Arthroplasty
1
2
3
4
1
2
3
4
Rheumatoid Arthritic Disease
1
2
3
4
1
2
3
4
Joint Replacement
1
2
3
4
1
2
3
4
Immunology/Hematology/Oncology
Patient Experience
Cancer
1
2
3
4
1
2
3
4
HIV/AIDS
1
2
3
4
1
2
3
4
Sickle Cell Anemia
1
2
3
4
1
2
3
4
Acute Leukemia
1
2
3
4
1
2
3
4
Chemo/Radiation
1
2
3
4
1
2
3
4
Sepsis
1
2
3
4
1
2
3
4
Labs
Hematology
1
2
3
4
1
2
3
4
Wounds/Integument
Assess
S/S Infection
1
2
3
4
1
2
3
4
Skin Turgor
1
2
3
4
1
2
3
4
Skin Assessment
1
2
3
4
1
2
3
4
Patient Experience
Burns
1
2
3
4
1
2
3
4
Pressure Sores
1
2
3
4
1
2
3
4
Staged Decubitus Ulcers
1
2
3
4
1
2
3
4
Surgical Wounds with Drains
1
2
3
4
1
2
3
4
Traumatic Wounds
1
2
3
4
1
2
3
4
Stasis Ulcers
1
2
3
4
1
2
3
4
Surgical Wounds
1
2
3
4
1
2
3
4
Monitor
Skin Breakdown
1
2
3
4
1
2
3
4
Medications/Therapeutic Interventions
Medications Administration
Administer IM and SQ Medications
1
2
3
4
1
2
3
4
Administer Inhalation Medications
1
2
3
4
1
2
3
4
Administer IV Piggybacks
1
2
3
4
1
2
3
4
Administer PO Medications
1
2
3
4
1
2
3
4
Mixing IV Solutions
1
2
3
4
1
2
3
4
IV Therapy
Adverse Reactions
1
2
3
4
1
2
3
4
Assess IV Insertion Site
1
2
3
4
1
2
3
4
Multi-lumen Central Venous Catheters
1
2
3
4
1
2
3
4
Central Lumen Catheters - PICCs
1
2
3
4
1
2
3
4
Central Lumen Catheters
1
2
3
4
1
2
3
4
Inserting IVs
1
2
3
4
1
2
3
4
Central Line Care
1
2
3
4
1
2
3
4
Nutritional Therapy
Enteral Administration
1
2
3
4
1
2
3
4
TPN and Hyperalimentation
1
2
3
4
1
2
3
4
Gravity/Bolus Tube Feedings
1
2
3
4
1
2
3
4
PEG
1
2
3
4
1
2
3
4
J-tube
1
2
3
4
1
2
3
4
Oxygen Administration
Nasal Cannula
1
2
3
4
1
2
3
4
Portable Oxygen
1
2
3
4
1
2
3
4
Tracheostomy Tube
1
2
3
4
1
2
3
4
Pain Management
Assess Pain Level/Tolerance
1
2
3
4
1
2
3
4
Patient Controlled Analgesia
1
2
3
4
1
2
3
4
Procedures/Equipment
Perform
CPM Machine
1
2
3
4
1
2
3
4
Doppler
1
2
3
4
1
2
3
4
Dressing Changes
1
2
3
4
1
2
3
4
Drains (JP-Hemovac-Penrose)
1
2
3
4
1
2
3
4
Suctioning (Oral-Naso-Pharynx)
1
2
3
4
1
2
3
4
Foley, 3-way
1
2
3
4
1
2
3
4
Foley, Female
1
2
3
4
1
2
3
4
Foley, Male
1
2
3
4
1
2
3
4
Isolation
1
2
3
4
1
2
3
4
Pulse-a-vac Irrigation
1
2
3
4
1
2
3
4
Specialty Beds
1
2
3
4
1
2
3
4
Sterile Dressing Changes
1
2
3
4
1
2
3
4
Tracheostomy Care/Suctioning
1
2
3
4
1
2
3
4
Universal Precautions
1
2
3
4
1
2
3
4
Wound Vac
1
2
3
4
1
2
3
4
Wound Care/Irrigations
1
2
3
4
1
2
3
4
Appropriate Blood Collection Tubes
Blood Cultures
1
2
3
4
1
2
3
4
Brown-topped (Lead)
1
2
3
4
1
2
3
4
Gray-topped (Fluoride,Potassium Oxalate)
1
2
3
4
1
2
3
4
Green-topped (Heparin,Ammonia)
1
2
3
4
1
2
3
4
Lt. Blue-topped(Coagulation)
1
2
3
4
1
2
3
4
Purple-topped (EDTA)
1
2
3
4
1
2
3
4
Red-topped (Plain)
1
2
3
4
1
2
3
4
Serum Separation (Tiger-top,Speckled, etc.)
1
2
3
4
1
2
3
4
Venipuncture Procedures
Apply Site Pressure Post Draw
1
2
3
4
1
2
3
4
Bandage Post Draw
1
2
3
4
1
2
3
4
Decontamination of Puncture Site
1
2
3
4
1
2
3
4
Insert Tube Post Draw
1
2
3
4
1
2
3
4
Order of Specimen Collection
1
2
3
4
1
2
3
4
Proper Waste/Sharps Disposal
1
2
3
4
1
2
3
4
Specialized Specimen Handling (Ice ect.)
1
2
3
4
1
2
3
4
Specimen ID and Labeling
1
2
3
4
1
2
3
4
Supplies for Venipuncture
1
2
3
4
1
2
3
4
Test Requisitions
1
2
3
4
1
2
3
4
Tourniquet Application
1
2
3
4
1
2
3
4
Tourniquet Removal
1
2
3
4
1
2
3
4
Transportation of Specimen to Lab
1
2
3
4
1
2
3
4
Venipuncture Sites
1
2
3
4
1
2
3
4
Warming the Puncture Site
1
2
3
4
1
2
3
4
Age Group Experience
Age Groups
0 - 30 Days
1
2
3
4
1
2
3
4
30 Days - 1 Year
1
2
3
4
1
2
3
4
1 - 3 Years
1
2
3
4
1
2
3
4
3 - 5 Years
1
2
3
4
1
2
3
4
5 - 12 Years
1
2
3
4
1
2
3
4
12 - 18 Years
1
2
3
4
1
2
3
4
18 - 39 Years
1
2
3
4
1
2
3
4
39 - 64 Years
1
2
3
4
1
2
3
4
64+ Years
1
2
3
4
1
2
3
4
Statement of Agreement
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 the Company to release this Home Health RN Checklist to their Client facilities in relation to consideration of employment as a Traveler with those facilities.
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