The following checklist is a profile used to assess your Medical/Surgery proficiency and assist in matching your skills with available assignments. Your employment is not dependent upon responses given on this checklist. Please rate your ability as accurately as possible by checking the appropriate option. Step 1 of 5 20% Name* First Middle Last PLEASE MARK YOUR LEVEL OF EXPERIENCE 0 - No Experience 1 - Theory/Observed Only 2 - Intermittent Experience 3 - Moderate Experience 4 – Expert General SkillsAdvanced directives01234Patient/family teaching01234Restrictive devices (restraints)01234Lift/transfer devices01234Specialty beds01234End of life care/palliative care01234Automated Medication Dispensing System, Pyxis, Omnicell, or other01234Bar coding for medication administration01234National Patient Safety Goals01234Accurate patient identification01234Effective communication01234Interpretation & communication of lab values01234Medication administration01234Labeling01234Anticoagulation therapy01234Reconciliation01234Monitoring conscious sedation01234Pain assessment & management01234Use of PCA (IV, intrathecal, epidural)01234Infection control01234Universal precautions01234Isolation01234Minimize risk for falls01234Prevention of pressure ulcers01234Wound care01234Wound vacs01234Awareness of HCAHPS01234Cardiac Monitoring & Emergency CareObtains 12 lead EKG01234Interpretation of rhythm strips01234Treatment of dysrythmias01234Use of rapid response teams01234Cardiac arrest/CPR01234O2 therapy & delivery01234Pulse oximetry01234Use of doppler01234 IV TherapyStarting & maintaining peripheral IVs01234Blood draw: venous01234Central line care01234Blood draw: central line01234Care & management of ports01234Care & management of PICC/Groshong/Hickman01234TPN & lipids01234Administration of blood/blood products01234Administration of chemotherapy01234Monitoring chemotherapy (does not initiate)01234OtherDiabetes mellitus01234Blood Glucose Monitoring (BGM)01234Insulin administration01234CardiacAssessment of heart sounds01234Pacemakers - permanent01234Cardiac - Care of Patient with:Aneurysm01234Angina01234Angioplasty (pre/post)01234CHF01234Carotid endarterectomy01234Post MI01234Pre/post cardiac cath01234Pre/post cardiac surgery01234Cardiac - Use & Administration of the Following:Antiarrhythmic01234Antihypertensives01234Beta blockers01234Diuretics01234Nitrates01234Fibrinolytics/IIb IIIa inhibitors01234RespiratoryAssessment of breath sounds01234Chest tubes (Emerson/Pleuravac)01234Interpretation of ABG01234Incentive spirometer01234Mechanical ventilation01234Oral suctioning01234Nasotracheal suctioning01234Tracheostomy care01234Respiratory - Care of Patient with:COPD01234Pre/post thoracic surgery01234Thyroidectomy01234Pulmonary embolism01234Pulmonary edema01234Pneumothorax01234Pneumonia01234Inhalation injuries01234Tuberculosis01234Emphysema01234Asthma01234Respiratory - Use & Administration of the Following:Bronchodilators01234Steroids01234Expectorants01234 GynecologyEndometriosis01234Gyn exam/pap01234Self breast exam01234Tubal ligation01234Ectopic pregnancy01234Mastectomy/lumpectomy01234Hysterectomy (vaginal or TAHBSO)01234Repair of cystocele/rectocele01234Pelvic inflammatory disease01234Abnormal uterine bleeding01234NeurologyGlasgow coma scale01234Seizure precautions01234Assist with lumbar puncture01234Halo traction01234Neurology - Care of Patient with:CVA01234TIA01234Overdose01234Spinal cord injury/trauma01234Pre/post neuro surgery01234Cranial hemorrhage01234Delirium tremors01234Meningitis01234Neuromuscular diseases01234Neurology - Use & Administration of the Following:Antiepileptics01234Corticosteroids01234Steroids01234GastrointestinalNG tube insertion01234Management of small bore feeding tubes (Dobhoff, Keofeed)01234Jejunostomy tube01234PEG tube01234Gastrointestinal - Care of Patient with:Pancreatitis01234Hepatitis01234G.I. bleed01234Esophageal bleeding01234Esophageal bleeding01234Bowel obstruction01234Gastric bypass01234Gastric banding01234Whipple procedure01234Transplants (specify)01234Colostomy/ileostomy01234Paralytic ileus01234E.R.C.P01234Gastrointestinal - Use & Administration of the Following:Anticholinergics (antispas, bentyl or robinul)01234Cathartics01234Genitourinary/RenalCatheter insertion01234GU irrigations01234Nephrostomy tube01234Suprapubic tube01234 Genitourinary/Renal - Care of Patient with:Hemodialysis01234T.U.R.P.01234Shunts and fistulas01234Nephrectomy01234Peritoneal dialysis01234Renal transplant01234Chronic/acute renal failure01234OrthopedicTotal joint replacement01234Arthroscopic surgery01234Bucks extension01234Fasciotomy01234Fractures01234Spika cast/body cast01234Splints01234CPM01234TENS unit01234Cast care & removal01234Amputation01234Skeletal traction01234Ortho trauma01234Cervical fusion01234Laminectomy01234OtherCare of patient with sepsis01234Oncology01234Chemotherapy01234Radiation therapy01234Radiation implants01234Inpatient hospice01234Burn patients01234 CertificationsBLS/CPRYesNoExpiration Date MM DD YYYY ACLSYesNoExpiration Date MM DD YYYY CMSRNYesNoExpiration Date MM DD YYYY Other Certifications(not listed above)TypeExpiration Date MM/DD/YYYY Additional SkillsLeadership skills (team leader or charge nurse)01234Age Specific CompetenciesNewborn/neonate (birth-30 days)01234Infant (31 days-1 year)01234Toddler (ages 2-3 years)01234Preschool (ages 4-5 years)01234School age (ages 6-12 years)01234Adolescent (ages 13-21 years)01234Young adult (ages 22-39 years)01234Adult (ages 40-64 years)01234Older adult (ages 65-79 years)01234Elderly (ages 80+ years)01234Additional SkillsAdditional Training:Additional Equipment:AcceptanceThe information I have given is true and accurate to the best of my knowledge. In addition, I hereby authorize Fidelis Partners to release this Medical/Surgical Profile to client institutions of Fidelis Partners in consideration of my employment with that institution.Signature*
