Competency/Skills Self-Appraisal:

Skilled Nursing/LTC

RN LPN

Experience (within last 1 year) 0 - No Experience/Never Performed 1 - Some Experience/Needs Supervision 2 - Experienced/Able to perform with back up if needed 3 - Very Experienced/Expert/Able to Teach

I understand that the information provided in this application is true to the best of my knowledge. I authorize the release of the information in this document to Team Staffing Network, LLC and facilities where I may be employed.

Date:

GENERAL SKILLS 0 1 2 3

Accident/Incident Reports

Accurate patient Identification

Admission/Transfer Discharge

Advanced DirectivesAnticoagulation TherapyAutomated Medication Dispensing System, Pyxis, Omnicell, other

Awareness for HCAHPS

Awareness of Patient Rights

Bathing and Skin/oral/peri care

Bed/Chair Alarms

Care Plan Development

Charting/Doc/Consents

Confidentiality/HIPPA

Discharge Planning

Door Alarms

Dressing Changes

Drug Administration/Unit Dose System

Effective CommunicationElastic (TED) Hose/Stockings

Elopement ProtocolsPage 1

GENERAL SKILLS 0 1 2 3

End of Life care/Palliative Care

Fall Risk Assessment

General Patient Assessment, History and Physical

Infection Control

Interpretation & Communication of Lab ValuesIsolation

JCAHO-National Patient Safety Goals

Kardex/IV Kardex/Treatment Kardex

Lab Work-Ordering and Values

Labeling (medications/specimens)

Lift/Transfer devices

MDS Documentation

Medication Administration

Medication Documentation (MAR)

Medication Reconciliation

Minimize Risk for Falls

MRSA/VRSA

Signature

GENERAL SKILLS 0 1 2 3

Ordering Medications/Supplies

Ordering/Prepping Patients for Diagnostic Tests

Pain Assessment & Management

Patient Positioning, Ambulation & ROMPatient/Family TeachingPost Mortem Care & Arrangements

Prevention of Pressure Ulcers

Resident Bill of Rights

ROM/Amputation

Restraint Application/Procedure/Safety

Specialty beds

Specimen Collection

Universal Precautions

UR/Medicare Review

W10 or Interagency Forms

Placing/Maintaining/Patient on Tele

Post Angioplasty

Post Cardiac CathPost Cardiac Surgery

Pre/Post MI

Pulses/Circulation Checks

Running & Mounting Rhythm Strips

Thrombophlebitis

Wander Guard/Electronic Monitoring Devices

LEADERSHIP 0 1 2 3

Charge Nurse

Team Leader

Primary Nurse

Other (please specify):

CARDIAC 0 1 2 3

Aneurysm

Angina

Arterial Disease

Auscultation/Interpretation Breath &Heart Sounds

Basic Arrhythmia Interpretation

Blood Pressure-noninvasive

Cardiac Arrest/CPRCHFDopplerFluid & Electrolyte Imbalances

Hypertension

Lead Placement

Pacemaker- Permanent

RESPIRATORY 0 1 2 3

Ambu Bag

ARDS

Assessment/Auscultation Lung Sounds

Assist with Intubation/Airway

Asthma

Care of Patient on Ventilator

Chest Physiotherapy

COPD

Dressing Changes

Emphysema

Endo Tracheal Tube Suctioning

Establishing Airway

ET Tube

External CPAP

Face MasksIncentive SpirometryInhalers

Interpretation of ABG

Page 2

RESPIRATORY 0 1 2 3

Knowledge & Management of Vent Alarms

Nasal Cannula

Nasotracheal Suctioning

Nebulizer Use

O2 Therapy Cannula/facemask

Oral Suctioning

Oropharyngeal Suctioning

Pneumonia

Portable O2 Tank

Pulmonary Edema

Pulmonary EmbolismPulse Oximetry

Trach Collar

Tracheostomy Care

Tuberculosis

Use of IPPB

Neuromuscular Disease

Paralysis

Paraplegic Care

Parkinson’s Disease

Pathologic Reflexes

Post Head Injury (concussion)

Quadriplegic Care

Seizure Activity/Precautions

Spinal Cords Injury

Stroke (CVA)

TBI (Traumatic Brain Injury)

GENITOURINARY/RENAL 0 1 2 3

A & P Repair

Administration of Tube Feeding

Assessment of Abdominal Sounds

AV Fistula/Shunt

Bladder Irrigations-Continuous

Bladder Irrigations-Intermittent

Bowel Obstruction

Cath Care 3 Way/ Suprapubic

Chemstrips-Urinalysis

Cholecystitis/Cholecystitis

Cholecystectomy

Chronic/Acute Renal Failure

Colostomy/ Pooch Systems

Electrolyte Imbalance

Enterostomal Care

ERCPFlexible Feeding Tube (Corpak, Dobhoff)Fluid Balance

Foley Catheter Insertion/ Care

Gallbladder Disease

NEUROLOGY 0 1 2 3

Assessment of Neuro Signs

ALS (Amyotrophic Lateral Sclerosis

Alzheimer’s Disease/Dementia

Aneurysm Precautions

Cerebral Function

Closed Head Injury/Trauma

Coma

Cranial Nerves

CVA Cerebral Vascular Accident

DT’s Delirium Tremens

Glasgow Coma Scale

LOC Level of Consciousness

Multiple SclerosisPage 3

GENITOURINARY/RENAL 0 1 2 3

GI Bleed

Gravity Feeding

Hemoccult Test

Hemodialysis

Hepatitis

IBS

Ileostomy

Insertion Foley Cath Male/Female

Interpretation of BUN & Creatinine

Jejunostomy Tube

Kidney StonesLiver Failure

Management of Gastrostomy Tube

Nephrectomy

Nephrostomy Tube

NG Medication Administration

Nutritional Requirements

Pancreatitis

Paralytic Ileus

Peritoneal Dialysis

Placement of NG Tube

Post Op AV Shunt Care

Post renal Surgery

Renal Failure

Renal Transplant

Renal Trauma

Renal/Genitourinary Assessment

Saline Lavage

Shunts & Fistulas

Specimen Collection-24 hour

Specimen Collection-routine

Straining Urine

GENITOURINARY/RENAL 0 1 2 3

Suprapubic Catheter

T-Tube

Tube Feeding

TURP’s

Upper GI Endoscopy/Colonoscopy

UTI’s

Page 4

ORTHOPEDIC 0 1 2 3

Amputation

Arthroscopic Surgery

Assessment of Orthopedic patient

Buck Extension

Cast Care

Cast Removal

Cervical Collar

Circulation Checks

CPM Machines

Fracture Complications-Fat Embolus

Gait

Gait Belt

K-Wires/Steinman Pins

Lumbar Laminectomy

Osteoporosis

Patient Positioning-Hip

Patient Positioning-Lumbar

Pinned Fractures

Prosthesis Application

Prosthetic

Pulse/CMS Checks

Range Of Motion

Removal of hardware

Rheumatic/Arthritic Disease

Skin

Sling

ORTHOPEDIC 0 1 2 3

Spica/Body Cast

Splints

Standard Extremity Braces

Stump Wrapping

Suture/Staple Removal

Total Hip Replacement

Total Knee Replacement

Traction

Transfer Boards

Walker

Wheelchair

SKIN 0 1 2 3

Skin Assessment

Staged Decubitus Ulcers

Stasis Ulcers

Sterile Dressing Changes

Surgical Wound Healing

Surgical Wounds/Drains

Traumatic Wounds

Use of Air Bed

Wound Care/Surgical

Wound Care/Irrigation

Wound Care/Medical

Wound Vac

Page 5

ENDOCRINE/METABOLIC 0 1 2 3

Addison’s Disease

Diabetes Insipidus

Diabetes Mellitus

Graves Disease

Hypothyroidism

Indwelling Insulin Pump

Interpretation of Blood Glucose

Metabolic Assessment

Performing Finger Stick

Recognizing diabetic Complications/Emergencies

S/S Diabetic Coma

S/S Insulin Reaction

ThyroidectomyUse of Electronic Blood Glucose Monitor

SKIN 0 1 2 3

Assessment of Skin/Breakdown

Burns

Dressing Changes

Pressure Sores

EAR/NOSE/THROAT 0 1 2 3

Cataract Surgery

Ear Infections

Glaucoma

Nose Bleeds

INFECTIOUS DISEASE 0 1 2 3

AIDS

Fever Management

Hepatitis

Interpretation of Lab

Isolation Protocol

MRSA/VRSA

ONCOLOGY 0 1 2 3

Assessment of Oncology Patient

Blood Chemistry

Blood CountsFluid & Electrolyte Imbalance/DehydrationInpatient Hospice

Interpretation of Lab Results

ONCOLOGY 0 1 2 3

Leukemia

Nutritional Needs

Oncology Crisis

Pain Control

Post Surgical

Radiation Implant

Reverse Isolation Procedures

PATIENT TEACHING/OTHER 0 1 2 3

Accident/Incident Reports

Accu-Check/Glucomter

Advance Directives

Burn Patient

Care Plan Development

Caregiver/Family teaching

Diabetic Teaching

Elopement

Fall Risk Assessments

General Patient Teaching

Chemotherapy

Corticosteroids

Coumadin Therapy

Digoxin

Dilantin

Diuretics

Electrolyte & Replacement

Epinephrine

Fentanyl

Hydrocortisone

Insulin

IV Antibiotics

Klonopin

Lasix

Nitroglycerine

Oral Hypoglycemics

Phenobarbital

Prednisone

Procardia

Psychotropic Meds

Kardex/IV Kardex/Treatment Kardex

MAR

MDS Documentation

Nursing Admission Assessment

Page 6

VASCULAR 0 1 2 3

Air Occlusive Dressing

Angiocath/ Butterfly

Broviac

Central Line/Catheter DressingsCentral Venous Cath (Groshong) maintain/dsg/accessCVP ReadingsDrains (Hemovac, Jackson-Pratt, Penrose, etc)Drawing Blood From Central Line

Drawing Venous Blood

Groshong

Heparin Lock

Hickman

Infusion Pumps

IV Pump Set Up

IV Starts

IV/Heparin Lock

IV/Heparin Maintenance

Knowledge of Normal Serum Lab

Peripheral Line Dressings

PICC maintain/dsg/access

Port-a-cath access

PT/INR

TPN/Hyperalimentation

Ultrasonic Doppler

PATIENT TEACHING/OTHER 0 1 2 3

Pain Management

Pre-Post Surgical Teaching

Residence Bill of Rights

ROM/Ambulation

Universal Precautions/isolation

Page 7

MEDICATION ADMINISTRATION 0 1 2 3

Alupent

Aminophyline

Antianginals

Antiarrythmics

Anticonvulsant Meds

Antihypertensives

Antiliperrics

Ativan

Cardizem

Sedation in Elderly Population

Sinemet

Steriods

Sub Q Heparin

Tegretol

Thyroid Medications

Valium

Versed

AGE SPECIFIC COMPETENCIES 0 1 2 3

Newborn/Neonate (birth-30 days)

Infant (31 days-1 year)

Toddler (2-3 years)

Preschool (4-5 years)

School Age (6-12 years)Adolescents (13-21 years)

Young Adult (22-39 years)

Adults (40-64 years)

Older Adult (65-79 years)

Elderly (80 + years)