LDRP RN

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Name*

First Last

Phone*

Email*

Age Specific Care

Proficiency Rating

Frequency Rating

Newborn/Neonate (birth - 30 days) *

Newborn/Neonate (birth - 30 days) proficiency*

Newborn/Neonate (birth - 30 days) frequency*

Infant (30 days - 1 year) *

Infant (30 days - 1 year) proficiency*

Infant (30 days - 1 year) frequency*

Toddler (1 - 3 years) *

Toddler (1 - 3 years) proficiency*

Toddler (1 - 3 years) frequency*

Preschooler (3 - 5 years) *

Preschooler (3 - 5 years) proficiency*

Preschooler (3 - 5 years) frequency*

School Age Child (5 - 12 years) *

School Age Child (5 - 12 years) proficiency*

School Age Child (5 - 12 years) frequency*

Adolescents (12 - 18 years) *

Adolescents (12 - 18 years) proficiency*

Adolescents (12 - 18 years) frequency*

Young Adults (18 - 39 years) *

Young Adults (18 - 39 years) proficiency*

Young Adults (18 - 39 years) frequency*

Middle Adults (39 - 64 years) *

Middle Adults (39 - 64 years) proficiency*

Middle Adults (39 - 64 years) frequency*

Older Adults (64+ years) *

Older Adults (64+ years) proficiency*

Older Adults (64+ years) frequency*

Elderly Adults (over 79+ years) *

Elderly Adults (over 79+ years) proficiency*

Elderly Adults (over 79+ years) frequency*

General Skills

Proficiency Rating

Frequency Rating

Patient and Family Teaching *

Patient and Family Teaching proficiency*

Patient and Family Teaching frequency*

Coaching Needs *

Coaching Needs proficiency*

Coaching Needs frequency*

Universal Precautions *

Universal Precautions proficiency*

Universal Precautions frequency*

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Care of the Patient in restraints *

Care of the Patient in restraints proficiency*

Care of the Patient in restraints frequency*

Cardiac Monitoring *

Cardiac Monitoring proficiency*

Cardiac Monitoring frequency*

Pulse Oximetry *

Pulse Oximetry proficiency*

Pulse Oximetry frequency*

Ventilator Management (Adult) *

Ventilator Management (Adult) proficiency*

Ventilator Management (Adult) frequency*

Ventilator Management (Newborn) *

Ventilator Management (Newborn) proficiency*

Ventilator Management (Newborn) frequency*

Prep and Administration of Emergency Meds *

Prep and Administration of Emergency Meds proficiency*

Prep and Administration of Emergency Meds frequency*

Infant / Neonatal Cardiac / Respiratory Arrest *

Infant / Neonatal Cardiac / Respiratory Arrest proficiency*

Infant / Neonatal Cardiac / Respiratory Arrest frequency*

Adult Cardiac / Respiratory Arrest *

Adult Cardiac / Respiratory Arrest proficiency*

Adult Cardiac / Respiratory Arrest frequency*

End of Life Care *

End of Life Care proficiency*

End of Life Care frequency*

Fetal Monitoring - Basic *

Fetal Monitoring - Basic proficiency*

Fetal Monitoring - Basic frequency*

Fetal Monitoring - Advanced *

Fetal Monitoring - Advanced proficiency*

Fetal Monitoring - Advanced frequency*

IV Therapy *

IV Therapy proficiency*

IV Therapy frequency*

Administration of Blood / Blood Products *

Administration of Blood / Blood Products proficiency*

Administration of Blood / Blood Products frequency*

Knowledge of Normal Lab Values *

Knowledge of Normal Lab Values proficiency*

Knowledge of Normal Lab Values frequency*

Newborn *

Newborn proficiency*

Newborn frequency*

Labor Patient *

Labor Patient proficiency*

Labor Patient frequency*

Pain Management *

Pain Management proficiency*

Pain Management frequency*

Automated Med Dispensing Systems *

Automated Med Dispensing Systems proficiency*

Automated Med Dispensing Systems frequency*

List Types:

Automated Med Dispensing Systems *

Automated Med Dispensing Systems proficiency*

Automated Med Dispensing Systems frequency*

List Types:

Automated Med Dispensing Systems *

Automated Med Dispensing Systems proficiency*

Automated Med Dispensing Systems frequency*

List Types:

Automated Med Dispensing Systems *

Automated Med Dispensing Systems proficiency*

Automated Med Dispensing Systems frequency*

List Types:

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Care of Patients with Pre - Existing Conditions / High Risk OB

Proficiency Rating

Frequency Rating

Cardiac Disease *

Cardiac Disease proficiency*

Cardiac Disease frequency*

Neurological Disease *

Neurological Disease proficiency*

Neurological Disease frequency*

Seizure Disorder *

Seizure Disorder proficiency*

Seizure Disorder frequency*

Chronic Diabetes Mellitus *

Chronic Diabetes Mellitus proficiency*

Chronic Diabetes Mellitus frequency*

Pregnancy Induced Diabetes Mellitus *

Pregnancy Induced Diabetes Mellitus proficiency*

Pregnancy Induced Diabetes Mellitus frequency*

Asthma *

Asthma proficiency*

Asthma frequency*

Chronic Hypertension *

Chronic Hypertension proficiency*

Chronic Hypertension frequency*

Pregnancy - Induced Hypertension *

Pregnancy - Induced Hypertension proficiency*

Pregnancy - Induced Hypertension frequency*

Infectious Disease *

Infectious Disease proficiency*

Infectious Disease frequency*

HBV *

HBV proficiency*

HBV frequency*

HIV *

HIV proficiency*

HIV frequency*

Sickle Cell Disease *

Sickle Cell Disease proficiency*

Sickle Cell Disease frequency*

RH Incompatibilities *

RH Incompatibilities proficiency*

RH Incompatibilities frequency*

Hemolytic Anemia *

Hemolytic Anemia proficiency*

Hemolytic Anemia frequency*

Collagen Vascular Disease *

Collagen Vascular Disease proficiency*

Collagen Vascular Disease frequency*

Hemorrhage *

Hemorrhage proficiency*

Hemorrhage frequency*

Drug Addiction / Withdrawal *

Drug Addiction / Withdrawal proficiency*

Drug Addiction / Withdrawal frequency*

Pyelonephritis *

Pyelonephritis proficiency*

Pyelonephritis frequency*

Abruptio Placenta *

Abruptio Placenta proficiency*

Abruptio Placenta frequency*

Placenta Previa *

Placenta Previa proficiency*

Placenta Previa frequency*

Placenta Acreta *

Placenta Acreta proficiency*

Placenta Acreta frequency*

Pre-Eclampsia *

Preeclampsia proficiency*

Preeclampsia frequency*

Eclampsia *

Eclampsia proficiency*

Eclampsia frequency*

Premature Labor *

Premature Labor proficiency*

Premature Labor frequency*

Malpresentations *

Malpresentations proficiency*

Malpresentations frequency*

Breech *

Breech proficiency*

Breech frequency*

Transverse Lie / Shoulder *

Transverse Lie / Shoulder proficiency*

Transverse Lie / Shoulder frequency*

Face Presentation *

Face Presentation proficiency*

Face Presentation frequency*

Brow Presentation *

Brow Presentation proficiency*

Brow Presentation frequency*

Multiple Gestation *

Multiple Gestation proficiency*

Multiple Gestation frequency*

PROM *

PROM proficiency*

PROM frequency*

Chorioamnionitis *

Chorioamnionitis proficiency*

Chorioamnionitis frequency*

Poly / Oligohydramnios *

Poly / Oligohydramnios proficiency*

Poly / Oligohydramnios frequency*

Prior Tubal Ligation *

Prior Tubal Ligation proficiency*

Prior Tubal Ligation frequency*

VBAC Management / Trial of Labor *

VBAC Management / Trial of Labor proficiency*

VBAC Management / Trial of Labor frequency*

Uterine Rupture *

Uterine Rupture proficiency*

Uterine Rupture frequency*

Incompetent Cervix (Shirodkar Suture / Cerclage) *

Incompetent Cervix (Shirodkar Suture / Cerclage) proficiency*

Incompetent Cervix (Shirodkar Suture / Cerclage) frequency*

Spontaneous Abortions - Complete / Incomplete *

Spontaneous Abortions - Complete / Incomplete proficiency*

Spontaneous Abortions - Complete / Incomplete frequency*

Intrauterine Growth Retardation (IUGR) *

Intrauterine Growth Retardation (IUGR) proficiency*

Intrauterine Growth Retardation (IUGR) frequency*

Postdate Pregnancy *

Postdate Pregnancy proficiency*

Postdate Pregnancy frequency*

HELLP Syndrome *

HELLP Syndrome proficiency*

HELLP Syndrome frequency*

DIC *

DIC proficiency*

DIC frequency*

Fetal Demise *

Fetal Demise proficiency*

Fetal Demise frequency*

Antepartum

Proficiency Rating

Frequency Rating

Triage of Obstetrical Patients *

Triage of Obstetrical Patients proficiency*

Triage of Obstetrical Patients frequency*

Assessment of Birth Plan *

Assessment of Birth Plan proficiency*

Assessment of Birth Plan frequency*

Perform Admission Risk Assessment *

Perform Admission Risk Assessment proficiency*

Perform Admission Risk Assessment frequency*

Non - Stress Test (NST) *

Non - Stress Test (NST) proficiency*

Non - Stress Test (NST) frequency*

Induction of Labor *

Induction of Labor proficiency*

Induction of Labor frequency*

Oxytocin Challenge Tests (OCT) *

Oxytocin Challenge Tests (OCT) proficiency*

Oxytocin Challenge Tests (OCT) frequency*

Biophysical Profile *

Biophysical Profile proficiency*

Biophysical Profile frequency*

Assist with Sonogram *

Assist with Sonogram proficiency*

Assist with Sonogram frequency*

Perform Sonogram *

Perform Sonogram proficiency*

Perform Sonogram frequency*

Assist with Amniocentesis *

Assist with Amniocentesis proficiency*

Assist with Amniocentesis frequency*

Normal Perinatal Vital Signs *

Normal Perinatal Vital Signs proficiency*

Normal Perinatal Vital Signs frequency*

Deep Tendon Reflex Checks (DTR’s) *

Deep Tendon Reflex Checks (DTR’s) proficiency*

Deep Tendon Reflex Checks (DTR’s) frequency*

Edema Assessment *

Edema Assessment proficiency*

Edema Assessment frequency*

Clonus *

Clonus proficiency*

Clonus frequency*

Assess for Comfort *

Assess for Comfort proficiency*

Assess for Comfort frequency*

Breathing / Relaxation Techniques *

Breathing / Relaxation Techniques proficiency*

Breathing / Relaxation Techniques frequency*

Coaching *

Coaching proficiency*

Coaching frequency*

Positioning *

Positioning proficiency*

Positioning frequency*

Medications

Proficiency Rating

Frequency Rating

Ritodrine *

Ritodrine proficiency*

Ritodrine frequency*

Magnesium Sulfate *

Magnesium Sulfate proficiency*

Magnesium Sulfate frequency*

Terbutaline *

Terbutaline proficiency*

Terbutaline frequency*

Indomethacin *

Indomethacin proficiency*

Indomethacin frequency*

Procardia *

Procardia proficiency*

Procardia frequency*

Pitocin *

Pitocin proficiency*

Pitocin frequency*

Oxytocin *

Oxytocin proficiency*

Oxytocin frequency*

Cervidil *

Cervidil proficiency*

Cervidil frequency*

Cytotec *

Cytotec proficiency*

Cytotec frequency*

Prostin Suppositories *

Prostin Suppositories proficiency*

Prostin Suppositories frequency*

Assist with Prostin Gel *

Assist with Prostin Gel proficiency*

Assist with Prostin Gel frequency*

Antibiotics *

Antibiotics proficiency*

Antibiotics frequency*

Antihypertensives *

Antihypertensives proficiency*

Antihypertensives frequency*

Heparin *

Heparin proficiency*

Heparin frequency*

Stadol *

Stadol proficiency*

Stadol frequency*

Nubain *

Nubain proficiency*

Nubain frequency*

Morphine *

Morphine proficiency*

Morphine frequency*

Demerol *

Demerol proficiency*

Demerol frequency*

Fentanyl *

Fentanyl proficiency*

Fentanyl frequency*

Insulin Drips *

Insulin Drips proficiency*

Insulin Drips frequency*

Insulin Pumps *

Insulin Pumps proficiency*

Insulin Pumps frequency*

Insulin SC *

Insulin SC proficiency*

Insulin SC frequency*

AZT / Other Antiviral Medications *

AZT / Other Antiviral Medications proficiency*

AZT / Other Antiviral Medications frequency*

Rhogam *

Rhogam proficiency*

Rhogam frequency*

IV Therapy / Procedures

Proficiency Rating

Frequency Rating

Starting PIVs *

Starting PIVs proficiency*

Starting PIVs frequency*

PICC Lines - Care and Maintenance *

PICC Lines - Care and Maintenance proficiency*

PICC Lines - Care and Maintenance frequency*

Central Venous Lines - Care and Maintenance *

Central Venous Lines - Care and Maintenance proficiency*

Central Venous Lines - Care and Maintenance frequency*

Invasive Hemodynamic Monitoring *

Invasive Hemodynamic Monitoring proficiency*

Invasive Hemodynamic Monitoring frequency*

Blood Draw from PICC / CVL *

Blood Draw from PICC / CVL proficiency*

Blood Draw from PICC / CVL frequency*

Administration of Blood / Blood Products *

Administration of Blood / Blood Products proficiency*

Administration of Blood / Blood Products frequency*

IV Infusion Pumps *

IV Infusion Pumps proficiency*

IV Infusion Pumps frequency*

Blood / Fluid Warmers *

Blood / Fluid Warmers proficiency*

Blood / Fluid Warmers frequency*

Labor Assessment / Procedures: Maternal:

Proficiency Rating

Frequency Rating

Normal Vital Signs - Baseline *

Normal Vital Signs - Baseline proficiency*

Normal Vital Signs - Baseline frequency*

Identify Common Cardiac Arrhythmias *

Identify Common Cardiac Arrhythmias proficiency*

Identify Common Cardiac Arrhythmias frequency*

Assist with Sterile Speculum Exam *

Assist with Sterile Speculum Exam proficiency*

Assist with Sterile Speculum Exam frequency*

Perform Sterile Speculum Exam *

Perform Sterile Speculum Exam proficiency*

Perform Sterile Speculum Exam frequency*

Vaginal Exam - Manual *

Vaginal Exam - Manual proficiency*

Vaginal Exam - Manual frequency*

Status of Membranes *

Status of Membranes proficiency*

Status of Membranes frequency*

Assist with Rupture of Membranes *

Assist with Rupture of Membranes proficiency*

Assist with Rupture of Membranes frequency*

Fern Test *

Fern Test proficiency*

Fern Test frequency*

Nitrazine *

Nitrazine proficiency*

Nitrazine frequency*

Presence of Clonus *

Presence of Clonus proficiency*

Presence of Clonus frequency*

DTRs *

DTRs proficiency*

DTRs frequency*

Edema *

Edema proficiency*

Edema frequency*

Progression Of Labor *

Progression Of Labor proficiency*

Progression Of Labor frequency*

Dilation *

Dilation proficiency*

Dilation frequency*

Effacement *

Effacement proficiency*

Effacement frequency*

Fetal Position *

Fetal Position proficiency*

Fetal Position frequency*

Fetal Presentation *

Fetal Presentation proficiency*

Fetal Presentation frequency*

Station *

Station proficiency*

Station frequency*

Contraction Characteristics *

Contraction Characteristics proficiency*

Contraction Characteristics frequency*

Determination of Fetal Head Position *

Determination of Fetal Head Position proficiency*

Determination of Fetal Head Position frequency*

Documentation of Labor Status and Interventions *

Documentation of Labor Status and Interventions proficiency*

Documentation of Labor Status and Interventions frequency*

Labor Suppressants *

Labor Suppressants proficiency*

Labor Suppressants frequency*

Collection of Blood Specimens *

Collection of Blood Specimens proficiency*

Collection of Blood Specimens frequency*

Collect Urine Specimens *

Collect Urine Specimens proficiency*

Collect Urine Specimens frequency*

Toxicology Studies *

Toxicology Studies proficiency*

Toxicology Studies frequency*

Collect Vaginal Cultures *

Collect Vaginal Cultures proficiency*

Collect Vaginal Cultures frequency*

Fluid *

Fluid proficiency*

Fluid frequency*

Herpes *

Herpes proficiency*

Herpes frequency*

Chlamydia *

Chlamydia proficiency*

Chlamydia frequency*

Group B Strep *

Group B Strep proficiency*

Group B Strep frequency*

Perform Leopold’s Maneuvers *

Perform Leopold’s Maneuvers proficiency*

Perform Leopold’s Maneuvers frequency*

AMNIOINFUSION (ASSIST OR PERFORM) FOR:

Variable Decelerations *

Variable Decelerations proficiency*

Variable Decelerations frequency*

Meconium *

Meconium proficiency*

Meconium frequency*

Prolapsed Cord *

Prolapsed Cord proficiency*

Prolapsed Cord frequency*

Vasa Previa *

Vasa Previa proficiency*

Vasa Previa frequency*

CATHETER INSERTION

Straight Cath *

Straight Cath proficiency*

Straight Cath frequency*

Foley *

Foley proficiency*

Foley frequency*

Labor Assessment / Procedures: Fetal:

Proficiency Rating

Frequency Rating

Fetal Heart Rate - Doppler *

Fetal Heart Rate - Doppler proficiency*

Fetal Heart Rate - Doppler frequency*

Fetal Heart Rate - Auscultate *

Fetal Heart Rate - Auscultate proficiency*

Fetal Heart Rate - Auscultate frequency*

Document Fetal Position *

Document Fetal Position proficiency*

Document Fetal Position frequency*

FETAL HEART RATE PATTERNS: IDENTIFY & TREAT BASELINE

Variability *

Variability proficiency*

Variability frequency*

Variable Decelerations *

Variable Decelerations proficiency*

Variable Decelerations frequency*

Early Decelerations *

Early Decelerations proficiency*

Early Decelerations frequency*

Late Decelerations *

Late Decelerations proficiency*

Late Decelerations frequency*

Prolonged Decelerations *

Prolonged Decelerations proficiency*

Prolonged Decelerations frequency*

External Fetal Monitor Application *

External Fetal Monitor Application proficiency*

External Fetal Monitor Application frequency*

Internal Fetal Monitor Application (Assist) *

Internal Fetal Monitor Application (Assist) proficiency*

Internal Fetal Monitor Application (Assist) frequency*

Internal Fetal Monitor Application (Perform) *

Internal Fetal Monitor Application (Perform) proficiency*

Internal Fetal Monitor Application (Perform) frequency*

Spiral Electrode *

Spiral Electrode proficiency*

Spiral Electrode frequency*

INTRAUTERINE PRESSURE CATHETER (IUPC)

Placement *

Placement proficiency*

Placement frequency*

Calibration *

Calibration proficiency*

Calibration frequency*

Fluid Filled *

Fluid Filled proficiency*

Fluid Filled frequency*

Transducer Tipped *

Transducer Tipped proficiency*

Transducer Tipped frequency*

Delivery / C-Section

Proficiency Rating

Frequency Rating

Assist with Vaginal Delivery *

Assist with Vaginal Delivery proficiency*

Assist with Vaginal Delivery frequency*

Forceps Extraction *

Forceps Extraction proficiency*

Forceps Extraction frequency*

Vacuum Extraction *

Vacuum Extraction proficiency*

Vacuum Extraction frequency*

Assist with High Risk Delivery *

Assist with High Risk Delivery proficiency*

Assist with High Risk Delivery frequency*

Shoulder Dystocia *

Shoulder Dystocia proficiency*

Shoulder Dystocia frequency*

Hemorrhage / Shock *

Hemorrhage / Shock proficiency*

Hemorrhage / Shock frequency*

Emergency Delivery *

Emergency Delivery proficiency*

Emergency Delivery frequency*

Abdominal Shave / Scrub Prep *

Abdominal Shave / Scrub Prep proficiency*

Abdominal Shave / Scrub Prep frequency*

Perineal Prep *

Perineal Prep proficiency*

Perineal Prep frequency*

Circulate for C-Section *

Circulate for C-Section proficiency*

Circulate for C-Section frequency*

Scrub for C-Section *

Scrub for C-Section proficiency*

Scrub for C-Section frequency*

Patient with General Anesthesia *

Patient with General Anesthesia proficiency*

Patient with General Anesthesia frequency*

Patient with Epidural Anesthesia *

Patient with Epidural Anesthesia proficiency*

Patient with Epidural Anesthesia frequency*

Circulate with Tubal Ligation *

Circulate with Tubal Ligation proficiency*

Circulate with Tubal Ligation frequency*

Scrub for Tubal Ligation *

Scrub for Tubal Ligation proficiency*

Scrub for Tubal Ligation frequency*

Assist with Placenta *

Assist with Placenta proficiency*

Assist with Placenta frequency*

Fundus Massage *

Fundus Massage proficiency*

Fundus Massage frequency*

Assist with Cervical Laceration Repair *

Assist with Cervical Laceration Repair proficiency*

Assist with Cervical Laceration Repair frequency*

Assist with Uterine Laceration Repair *

Assist with Uterine Laceration Repair proficiency*

Assist with Uterine Laceration Repair frequency*

Assist with Episiotomy Repair *

Assist with Episiotomy Repair proficiency*

Assist with Episiotomy Repair frequency*

Immediate Care of Newborn in Delivery Room

Proficiency Rating

Frequency Rating

NEWBORN ASSESSMENT

Ballard *

Ballard proficiency*

Ballard frequency*

Dubowitz *

Dubowitz proficiency*

Dubowitz frequency*

Finnegan / Abstinence Scoring *

Finnegan / Abstinence Scoring proficiency*

Finnegan / Abstinence Scoring frequency*

Apgar Scores *

Apgar Scores proficiency*

Apgar Scores frequency*

Initial Vital Signs *

Initial Vital Signs proficiency*

Initial Vital Signs frequency*

Bulb Suctioning *

Bulb Suctioning proficiency*

Bulb Suctioning frequency*

Delee Suctioning *

Delee Suctioning proficiency*

Delee Suctioning frequency*

Wall Suctioning *

Wall Suctioning proficiency*

Wall Suctioning frequency*

Meconium Aspiration *

Meconium Aspiration proficiency*

Meconium Aspiration frequency*

Collect Cord Samples *

Collect Cord Samples proficiency*

Collect Cord Samples frequency*

Assist with UAC / UVC Insertion *

Assist with UAC / UVC Insertion proficiency*

Assist with UAC / UVC Insertion frequency*

Insertion of IV, Including Scalp IV *

Insertion of IV, Including Scalp IV proficiency*

Insertion of IV, Including Scalp IV frequency*

Radiant Warmer / Thermoregulation *

Radiant Warmer / Thermoregulation proficiency*

Radiant Warmer / Thermoregulation frequency*

Interventions for LGA, SGA, IUGR *

Interventions for LGA, SGA, IUGR proficiency*

Interventions for LGA, SGA, IUGR frequency*

Interventions for Infant of Diabetic Mother *

Interventions for Infant of Diabetic Mother proficiency*

Interventions for Infant of Diabetic Mother frequency*

Oxygen Administration *

Oxygen Administration proficiency*

Oxygen Administration frequency*

Bag / Mask Ventilation of the Newborn *

Bag / Mask Ventilation of the Newborn proficiency*

Bag / Mask Ventilation of the Newborn frequency*

Assist with Intubation *

Assist with Intubation proficiency*

Assist with Intubation frequency*

Transport Isolette *

Transport Isolette proficiency*

Transport Isolette frequency*

Heelstick Glucose *

Heelstick Glucose proficiency*

Heelstick Glucose frequency*

Eye Prophylaxis *

Eye Prophylaxis proficiency*

Eye Prophylaxis frequency*

Vitamin K *

Vitamin K proficiency*

Vitamin K frequency*

ID / Security Banding *

ID / Security Banding proficiency*

ID / Security Banding frequency*

Promote Bonding Behaviors *

Promote Bonding Behaviors proficiency*

Promote Bonding Behaviors frequency*

Lead Placement for Cardiac Monitor *

Lead Placement for Cardiac Monitor proficiency*

Lead Placement for Cardiac Monitor frequency*

Apnea Monitoring *

Apnea Monitoring proficiency*

Apnea Monitoring frequency*

Oxyhood *

Oxyhood proficiency*

Oxyhood frequency*

Postpartum Care

Proficiency Rating

Frequency Rating

Fundal Height *

Fundal Height proficiency*

Fundal Height frequency*

Fundal Massage *

Fundal Massage proficiency*

Fundal Massage frequency*

Lochia *

Lochia proficiency*

Lochia frequency*

Episiotomy Care *

Episiotomy Care proficiency*

Episiotomy Care frequency*

Perineum Care *

Perineum Care proficiency*

Perineum Carefrequency*

Maternal Vital Signs *

Maternal Vital Signs proficiency*

Maternal Vital Signs--- frequency*

Recovering Post-Op C-Section Patients *

Recovering Post-Op C-Section Patients proficiency*

Recovering Post-Op C-Section Patients frequency*

Recovering Post-Op Tubal Ligation Patient *

Recovering Post-Op Tubal Ligation Patient proficiency*

Recovering Post-Op Tubal Ligation Patient frequency*

Fluid Balance *

Fluid Balance proficiency*

Fluid Balance frequency*

Fluid Balance *

Fluid Balance proficiency*

Fluid Balance frequency*

Couplet Care *

Couplet Care proficiency*

Couplet Care frequency*

Breast Care *

Breast Care proficiency*

Breast Care frequency*

Breastfeeding *

Breastfeeding proficiency*

Breastfeeding frequency*

Newborn Care

Proficiency Rating

Frequency Rating

Cord Care *

Cord Care proficiency*

Cord Care frequency*

Circumcision Care *

Circumcision Care proficiency*

Circumcision Care frequency*

Bath Demonstration *

Bath Demonstration proficiency*

Bath Demonstration frequency*

Assist with Lumbar *

Assist with Lumbar proficiency*

Assist with Lumbar frequency*

Administration of IV Antibiotics *

Administration of IV Antibiotics proficiency*

Administration of IV Antibiotics frequency*

Newborn Vital Signs *

Newborn Vital Signs proficiency*

Newborn Vital Signs frequency*

ASSIST WITH BREASTFEEDING

Latch On *

Latch On proficiency*

Latch On frequency*

Positioning *

Positioning proficiency*

Positioning frequency*

Care of the Infant with:

Proficiency Rating

Frequency Rating

Cardiac Anomalies *

Cardiac Anomalies proficiency*

Cardiac Anomalies frequency*

Drug Addiction / Withdrawal *

Drug Addiction / Withdrawal proficiency*

Drug Addiction / Withdrawal frequency*

Cystic Fibrosis *

Cystic Fibrosis proficiency*

Cystic Fibrosis frequency*

Meconium Aspiration *

Meconium Aspiration proficiency*

Meconium Aspiration frequency*

Pneumonia *

Pneumonia proficiency*

Pneumonia frequency*

Pulmonary Edema *

Pulmonary Edema proficiency*

Pulmonary Edema frequency*

RDS *

RDS proficiency*

RDS frequency*

NEC *

NEC proficiency*

NEC frequency*

Neuromuscular Disease *

Neuromuscular Disease proficiency*

Neuromuscular Disease frequency*

Spina Bifida *

Spina Bifida proficiency*

Spina Bifida frequency*

Seizure Activity *

Seizure Activity proficiency*

Seizure Activity frequency*

Tracheoesophageal Fistula *

Tracheoesophageal Fistula proficiency*

Tracheoesophageal Fistula frequency*

Sepsis *

Sepsis proficiency*

Sepsis frequency*

Sickle Cell Disease *

Sickle Cell Disease proficiency*

Sickle Cell Disease frequency*

Low Birth Weight Infants *

Low Birth Weight Infants proficiency*

Low Birth Weight Infants frequency*

Pain Management / Anesthesia

Proficiency Rating

Frequency Rating

Assess Pain Level *

Assess Pain Level proficiency*

Assess Pain Level frequency*

Assess Acceptable Level of Pain *

Assess Acceptable Level of Pain proficiency*

Assess Acceptable Level of Pain frequency*

Intranasal Pain Medications *

Intranasal Pain Medications proficiency*

Intranasal Pain Medications frequency*

Oral Pain Medications *

Oral Pain Medications proficiency*

Oral Pain Medications frequency*

IV Pain Medications *

IV Pain Medications proficiency*

IV Pain Medications frequency*

PCA *

PCA proficiency*

PCA frequency*

IV Conscious Sedation *

IV Conscious Sedation proficiency*

IV Conscious Sedation frequency*

Epidural Pain Management *

Epidural Pain Management proficiency*

Epidural Pain Management frequency*

Intervention for Anesthesia Toxicity *

Intervention for Anesthesia Toxicity proficiency*

Intervention for Anesthesia Toxicity frequency*

ASSIST WITH EPIDURAL INSERTION

Positioning of Patient *

Positioning of Patient proficiency*

Positioning of Patient frequency*

Signs of Dural Puncture *

Signs of Dural Puncture proficiency*

Signs of Dural Puncture frequency*

Fluid Challenge *

Fluid Challenge proficiency*

Fluid Challenge frequency*

Hypotension *

Hypotension proficiency*

Hypotension frequency*

Intrathecal Narcotics *

Intrathecal Narcotics proficiency*

Intrathecal Narcotics frequency*

Miscellaneous

List Any Additional Training:

List Any Additional Skills:

List Any Additional Equipment:

Do you have Experience with ventilators?*

Yes

List Types:

Do you have Experience with cardiac monitors?*

Yes

List Types:

Do you have Experience with NRP Current?*

Yes

Do you have Experience with STABLE Current?*

Yes

Fetal monitoring course - basic?*

Yes

Fetal monitoring course - intermediate?*

Yes

Fetal monitoring course - advanced?*

Yes

Please list the number of years of your experience in:

Labor and Delivery*

LDR*

LDRP*

Rural Hospital (Also list number of births per month):*

Community Hospital (Also list number of births per month):*

Number of deliveries attended per month (average in last year):*

Have you ever experienced an unattended delivery?*

Yes

Certify your information*

I certify that I have provided true and accurate information about my skills and experience to the best of my ability

Signature*

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Date*

Skills/Competences

Proficiency

Frequency

LDRP RN

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