Patient Care Technician

Skills Checklist

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Print Name Last 4 of SS # Date Completed

Directions

Please circle a value for each question to

provide us and the interested facilities with

an assessment of your clinical experience.

These values confirm your strengths within

your specialty and assist the facility in the

selection process of the healthcare

professional.

Experience

   1 - No Experience (has never done or observed)

   2 - Requires Training (In-Service) - not performed within last 36 months

   3 - Limited Experience (requires assistance or training) - performed within the last 24 months

   4 - Experienced (routinely performs without assistance) - performed within the last 12 months

   5 - Able to Supervise, Precept and Teach - performed within the last 6 months

ACTIVITIES OF DAILY LIVING Experience

   PERFORM FOOT CARE 1 2 3 4 5

   FEEDING PATIENT 1 2 3 4 5

   SHAVE PATIENT 1 2 3 4 5

   PERFORM DECUBITUS ULCER CARE 1 2 3 4 5

   ASSIST WITH GAIT TRAINING 1 2 3 4 5

   ASSIST WITH TUB BATH 1 2 3 4 5

   CHANGE UNOCCUPIED BED 1 2 3 4 5

   ORIENT PATIENT 1 2 3 4 5

   POSITION & TURN PATIENT 1 2 3 4 5

   PERFORM COMPLETE BED BATH 1 2 3 4 5

   PERFORM ORAL HYGIENE 1 2 3 4 5

   ASSIST WITH AMBULATION 1 2 3 4 5

   PERFORM SKIN CARE 1 2 3 4 5

   ASSIST WITH SHOWER 1 2 3 4 5

   CHANGE OCCUPIED BED 1 2 3 4 5

   PERFORM PASSIVE / ACTIVE ROM 1 2 3 4 5

   SHAMPOO BEDRIDDEN PATIENT 1 2 3 4 5

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Patient Care Technician

Skills Checklist

ACTIVITIES OF DAILY LIVING Experience

   TRANSFER PATIENT TO GURNEY 1 2 3 4 5

TRANSFER PATIENT TO Experience

   BODY MECHANICS 1 2 3 4 5

   TRANSFER PATIENT TO WHEELCHAIR 1 2 3 4 5

   TRANSFER PATIENT TO CHAIR 1 2 3 4 5

   TRANSFER PATIENT TO TOILET 1 2 3 4 5

   TURN & POSITION PATIENT 1 2 3 4 5

   PULLING & LIFTING PATIENT 1 2 3 4 5

EQUIPMENT Experience

   OXYGEN MASK 1 2 3 4 5

   HUMIDIFIER 1 2 3 4 5

   BED SCALE 1 2 3 4 5

   THERMOMETER (ELECTRIC / GLASS) 1 2 3 4 5

   HOYER LIFT 1 2 3 4 5

   OXYGEN CANNULA 1 2 3 4 5

   TED STOCKINGS 1 2 3 4 5

   BLOOD PRESSURE CUFF - MANUAL 1 2 3 4 5

   BLOOD PRESSURE CUFF - ELECTRIC 1 2 3 4 5

SPECIMEN COLLECTION Experience

   STOOL SPECIMEN 1 2 3 4 5

   24 HOUR URINE SPECIMEN 1 2 3 4 5

   URINE CULTURE 1 2 3 4 5

   SPUTUM SPECIMEN 1 2 3 4 5

   FOLEY CATHETERS SPECIMEN 1 2 3 4 5

   SPECIFIC GRAVITY OF URINE 1 2 3 4 5

   STOOL HEMOCULT 1 2 3 4 5

   CLEAN VOIDED URINE 1 2 3 4 5

   MIDSTREAM URINE CATCH 1 2 3 4 5

   STOOL PARASITES 1 2 3 4 5

   

   

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Patient Care Technician

Skills Checklist

VITAL SIGNS Experience

   NORMAL VITAL SIGNS 1 2 3 4 5

   ASSESS PULSE 1 2 3 4 5

ASSESS TEMPERATURE Experience

   ORAL 1 2 3 4 5

   RECTAL 1 2 3 4 5

   ASSESS RESPIRATIONS 1 2 3 4 5

   NORMAL VITAL SIGN IN PEDS 1 2 3 4 5

   ELECTRIC BP CUFF 1 2 3 4 5

OBSERVATIONS Experience

   NEED OF RESTRAINS 1 2 3 4 5

   DISPOSAL OF SHARPS 1 2 3 4 5

   ABNORMAL VITAL SIGNS 1 2 3 4 5

   NEED FOR PAIN MEDS 1 2 3 4 5

   RESPIRATORY DISTRESS 1 2 3 4 5

   ALTERED MENTAL STATUS 1 2 3 4 5

   NEED FOR SEDATION 1 2 3 4 5

   IDENTIFYING CHOKING PATIENT 1 2 3 4 5

PROCEDURES Experience

   OIL RETENTION ENEMA 1 2 3 4 5

   DRESSING CHANGES 1 2 3 4 5

   TUBE FEEDINGS 1 2 3 4 5

   ORAL SUCTIONING 1 2 3 4 5

   CATHETERIZATION 1 2 3 4 5

   ORAL CARE 1 2 3 4 5

   SOAP SUDS ENEMA 1 2 3 4 5

   OSTOMY CARE 1 2 3 4 5

   SALINE ENEMA 1 2 3 4 5

   TAP WATER ENEMA 1 2 3 4 5

   ADMISSIONS / DISCHARGES 1 2 3 4 5

   

   

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The information represented above is true and correct to the best of my knowledge. I also authorize

Specialty Professional Services, Corp to share the above skills checklist with its facility clients.

Patient Care Technician

Skills Checklist

INFECTION CONTROL Experience

   EQUIPMENT CLEANING 1 2 3 4 5

   WASTE DISPOSAL 1 2 3 4 5

   REVERSE ISOLATION 1 2 3 4 5

   RESPIRATORY ISOLATION 1 2 3 4 5

   UNIVERSAL PRECAUTIONS 1 2 3 4 5

   DISPOSAL OF SHARPS 1 2 3 4 5

RESTRAINTS Experience

   DOCUMENTATION 1 2 3 4 5

   OBSERVING RESTRAINED PATIENT 1 2 3 4 5

   APPLYING SOFT LIMB RESTRAINTS 1 2 3 4 5

   APPLYING POSEY RESTRAINTS 1 2 3 4 5

   SAFETY GUIDELINES 1 2 3 4 5

   APPLYING LEATHER RESTRAINTS 1 2 3 4 5

AGE APPROPRIATE CARE Experience

   NEWBORN (BIRTH-30 DAYS) 1 2 3 4 5

   INFANT (30 DAYS - 1 YEAR) 1 2 3 4 5

   TODDLER (1 - 3 YEARS) 1 2 3 4 5

   PRESCHOOLER (3 - 5 YEARS) 1 2 3 4 5

   SCHOOL AGE (5 - 12 YEARS) 1 2 3 4 5

   ADOLESCENTS (12 - 18 YEARS) 1 2 3 4 5

   YOUNG ADULTS (18 - 39 YEARS) 1 2 3 4 5

   MIDDLE ADULTS (39 - 64 YEARS) 1 2 3 4 5

   OLDER ADULTS (64+ YEARS) 1 2 3 4 5

   

   

   

   

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Signature Date Completed

Fax: 718-225-9421 Version: 07/03/2012 Page 4 out of 4