This checklist will be used to assess your suitability for placement.
Experience Guide
1 - Not Applicable -
minimal or no exposure to clinical aspect or care.
2 - Beginner -
sufficient knowledge to understand the contextual nature of the function, able to perform routine functions independently, requires assistance when setting priorities in complex situations, needs to gain speed and flexibility to be competent.
3 - Competent -
perceives situations and functions as a whole, has knowledge of the typical events to expect in a given situation and the appropriate responses, flexible in decision making.
4 - Proficient -
considerable background and experience, can grasp situations intuitively, mastery in performance, incorporates elements of innovation and creativity in clinical experience.
Treatment Setting
Treatment Setting
Experience 1 2 3 4
Adolescent Unit
Children's Unit
Chronic Psychiatric Facility
Eating Disorder Unit
Forensic Unit (Prison)
In Patient Acute Psychiatric Facility
IN Patient Hospital Unit
Locked Unit
Out Patient Clinic / Community Setting
Substance Abuse / rehab Unit
Familiarity Level with Psychiatric Disorders
Familiarity Level with psychiatric disorders
Experience 1 2 3 4
Anxiety Disorders
Congenital Disorders
Crisis Management
Degenerative Disorders
Eating Disorders
Mood Disorders
Organic Disorders
Pediatric / Adolescent Dysfunctions
Personality Disorders
Psychotic Disorders
Sexuality Dysfunction
Substance Abuse / Use
Clinic Assessment Tools
Clinic Assessment Tools
Experience 1 2 3 4
Childs Apperception Test
Gestalt Test
Informal Cognitive Status Assessment
Minnesota Multiphasic Personality Inventory
Rorschach Test
Stanford Binet Test
Thematic Aperception Test
Wechsler Intelligence Test
Wechsler Intelligence Test for Childreen
Communication Techniques
Communication Techniques
Experience 1 2 3 4
Active Listening
Clarification
Confronting
Focusing
Limit Setting
Positive Reinforcement
Questioning
Reality Orientation
Restatement / Reflection
Summarizing
Therapeutic Interventions
Department Specific Nursing Skills / Therapies
Department Specific Nursing Skills / Therapies
Experience 1 2 3 4
Behaviorist Charting
Behavior Modification
Behavior Therapy
Care of Alcoholic Patient
Care of Suicidal Patient
Care of the drug dependent patient
Care of the hallucinatory patient
Care of the manic patient
Care of the seizure patient
Care of the Violent Patient
Conducted group psychotherapy
Conducts individual psychotherapy
Crisis Counseling
Discharge planning
Elctro therapies
Milieu Tharapy
Participation in Multidisciplinary staffing
Patient teaching
Psychiatric Patient Intake
Psychotherapy
Rapid Tranquilization
Relationship Family Therapy
Therapeutic Communication Skills
Legal / Ethical Issues
General L
Experience 1 2 3 4
Informed consent
Intradermal Injections
Involuntary Commitment
Legal rights of the Mentally Ill
Right to refuse treatment
Terrasoff / Duty to Warn
Use of Restraints
Use of Seclusion
Voluntary Commitment
Skilled Nursing Care
General sn
Experience 1 2 3 4
Administration of Blood / Blood Products
Airway Management
Assess Circulaiton
Assessement / Management of Pain
Automated Medication Dispensing Systems
Blood Glucose Monitoring
Calcualte Total Intake and Output by Weight
Calculate IV Fluid Rates
Calculate Medication Dosages by Weight
Cardiac Arrest / ACLS Adults
Cardiac Arrest /CPR Pediatrics
Cardiac Monitoring
Care of Isolation Patient
Care of Restrained Patient
Coaching Family Needs: Physical / Emotional / Comfort
Computer Documentation
Dressing Changes
Electrolyte balance/replacement
End of Life Care
Glascow Coma Scale
Heparin lock and saline flush
Iintavenous Infusions / Buretrol / Soluset
Infusion Pumps
Interpretation of ABGs
Intramuscular Injections
Intramuscular route
IV Piggyback
IV Push
Knowledge and Communication of Normal Lab Values
Lift / Transfer Devicess
Management of Fluid / Electrolyte Balance
Neuro Assessment
NG Tube Insertion / Maintenance
Oral / Nasotracheal Suctioning
Oxygen Delivery
Patient / Family Teaching
PCA's
Peripheral IV's / Blood Draw
Pulse Oximetry
Scalp Veins
Seizure Precaution
Suctioning
TPN / Lipids
Universal Precautions
Urinary Catheter Insertion / Maintenance
Use of Doppler
Use of INfusion Pumps / IV Monitoring
Wound Care
Age Specific Practice Criteria
Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.
A.
New Born/Neonate
(Birth - 30 days)
B.
Infant
(30 days - 1 Year)
C.
Toddler
(1 - 3 Years)
D.
Preschooler
(3 - 5 Years)
E.
School age children
(5 - 12 Years)
F.
Adolescents
(12 - 18 Years)
G.
Young Adults
(18 - 39 Years)
H.
Middle Adults
(39 - 64 Years)
I.
Older Adults
( +64 Years)
Experience With Age Groups
Able to adapt care to incorporate normal growth and development
A
B
C
D
E
F
G
H
I
Able to adapt method and terminology of patient information to their age, comprehension and maturity level.
A
B
C
D
E
F
G
H
I
Can ensure a safe environment reflecting specific needs of varying age groups.
A
B
C
D
E
F
G
H
I
By submitting this checklist you agree to the following:
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 Skills Checklist to the Client facilities in relation to consideration of employment as a per diem nurse with those facilities.
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