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
Hospice / Palliative Care
Acute/Long Term Care – Pediatrics
Prevention/ Risk Assessment Tools – Adult
Prevention/ Risk Assessment Tools -Pediatrics
Support Surface Selection
PERIPHERAL ARTERIAL ULCERS
Fistulae – Pouching / Skin Care
Skin Care/ Management of Drains
Hyperbaric Oxygen Therapy
Enzymatic Debriding Agents
Ostomy Equipment Selection
Continence Skin Care Management
CONTINENCE THERAPEUTIC DEVICES
Internal Urethral Inserts
Catheters –Mgmt & Self Care Teaching
Urinary Incontinence Program
Fecal Incontinence Program
PROFESSIONAL KNOWLEDGE AND SKILLS
National Patient Safety Goals/ Core Measures
Age Specific/Population Based Care
Pain assessment & Management
Interpretation & Communication of Lab Values
Other Computerized System
Computerized Physician Order Entry
Bar coding for Medication
Pain Management Assessment of Pain Levels without intervention
Pain Management Response Assessment with Intervention
Young Adult (18-30 years)
Mature Adult (30-60 years)