Instructions: This checklist is
meant to serve as a general guideline for our client facilities as to the
level of your skills within your nursing specialty. Please use the scale
(PROFICIENCY)
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
(FREQUENCY)
1 = Never performed observed only
2 = Less than 6 times per year
3 = 1-2 times per month
4 = Daily or Weekly
PROFICIENCY / FREQUENCY
PROFICIENCY
FREQUENCY
Nursing Home/ Long-term Care Facility
Comprehensive physical assessment
Order, may perform, & interpret screening & diagnostic test
Ingestions and poisonings
Overdose of sedative, hypnotics, opiates
Family, support system, community resources
Consulting with Physicians
Consulting with Pharmacists
Consulting with Speech Therapist
Consulting with Dietician and Diet Aide
Consulting with Occupational Therapist
Referral to Pastoral Services
COPD (chronic obstructive pulmonary disease)
URI (upper respiratory infection)
Interpret ABG (blood gases)
Chronic obstructive pulmonary disease
Stasis ulcer of lower extremities
ASHD (arteriosclerotic heart disease)
PVD (peripheral vascular disease)
Interpreting 12 lead EKG’s
Abnormal pap smear findings
Fibrocystic breast disease
Preparation for childbirth
Pregnancy - diagnosis and referral
Pain relief in active phase of labor
Medications in the third stage
Dysfunctional uterine bleeding
Medications in the postpartum phase
Nausea and vomiting with pregnancy
Single layer wound closure
Acute purulent otitis media
Fluorescein staining of eyes
Minor sprains and strains
Benign prostatic hypertrophy
Enemas/ Suppositories/ Fecal
TIA (transient ischemic attacks)
Type II diabetes mellitus
Folic acid deficiency anemia
Knowledge of pharmacology
Knowledge of pharmacokinetics
Knowledge of drug interactions
Knowledge of side effects
Knowledge of potential adverse reactions:
Management/Titration of IV Therapies
IV/PO Antibiotic Therapy and understanding of cultures
Management of controlled substances
Non-Pharmacologic Interventions
Medical nutrition therapy
Cessation of substance abuse (alcohol, tobacco)
Mental health issues (stress management, depression)
Public health and health promotion
Leadership and teaching skills
Self evaluation to improve patient care
Working within scope of practice
Discharge planning / collaboration
Radiographic interpretation (initial)
Explanation to patient/family
OSHA (Occupational Safety and Health Administration)
CLIA waiver (Clinical Laboratory Improvement Amendments)
TJC (The Joint Commission)
HEDIS (Health Plan Employer Data and Information Set)
DQIP (Diabetes Quality Improvement Program)
HIPAA (Health Insurance Portability & Accountability Act)
Age Specific Competencies
Newborn/neonate (birth-30 days)
Preschool (ages 4-5 years)
School age (ages 6-12 years)
Adolescents (ages 13-21 years)
Young adult (ages 22-39 years)
Adults (ages 40-64 years)
Older adult (ages 65-79 years)