Name*
First
Last
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*
Work Setting
Proficiency Rating
Frequency Rating
Home Hospice *
Home Hospice proficiency* Home Hospice frequency* Inpatient Hospice *
Inpatient Hospice proficiency* Inpatient Hospice frequency* Pediatric Hospice *
Pediatric Hospice proficiency* Pediatric Hospice frequency* Home Health / Hospice Setting *
Home Health / Hospice Setting proficiency* Home Health / Hospice Setting frequency*
Assessment
Proficiency Rating
Frequency Rating
Intake Assessment *
Intake Assessment proficiency* Intake Assessment frequency* Assessment Interview *
Assessment Interview proficiency* Assessment Interview frequency* Physical Exam *
Physical Exam proficiency* Physical Exam frequency* Coping Status *
Coping Status proficiency* Coping Status frequency* Environmental Status *
Environmental Status proficiency* Environmental Status frequency*
Plan of Care
Proficiency Rating
Frequency Rating
Set Goals with Patient / Family *
Set Goals with Patient / Family proficiency* Set Goals with Patient / Family frequency* Collaborate with Other Team Members *
Collaborate with Other Team Members proficiency* Collaborate with Other Team Members frequency*
Symptom Management
Proficiency Rating
Frequency Rating
Urgent Assessment of Symptoms *
Urgent Assessment of Symptoms proficiency* Urgent Assessment of Symptoms frequency* Reduce Symptoms to Level Acceptable to Patient *
Reduce Symptoms to Level Acceptable to Patient proficiency* Reduce Symptoms to Level Acceptable to Patient frequency* Report Symptoms / Management to Provider *
Report Symptoms / Management to Provider proficiency* Report Symptoms / Management to Provider frequency* Treat Underlying Cause *
Treat Underlying Cause proficiency* Treat Underlying Cause frequency* Severity Scale *
Severity Scale proficiency* Severity Scale frequency* Management of Nausea *
Management of Nausea proficiency* Management of Nausea frequency* Management of Constipation *
Management of Constipation proficiency* Management of Constipation frequency* Management of Fatigue *
Management of Fatigue proficiency* Management of Fatigue frequency* Anorexia / Cachexia *
Anorexia / Cachexia proficiency* Anorexia / Cachexia frequency* Restlessness *
Restlessness proficiency* Restlessness frequency* Educate Family of Symptom Management *
Educate Family of Symptom Management proficiency* Educate Family of Symptom Management frequency*
Pain Management
Proficiency Rating
Frequency Rating
Identify Source of Pain *
Identify Source of Pain proficiency* Identify Source of Pain frequency* Pain Severity *
Pain Severity proficiency* Pain Severity frequency* PAINAD Scale for Non - Verbal Patient *
PAINAD Scale for Non - Verbal Patient proficiency* PAINAD Scale for Non - Verbal Patient frequency* Reduce Pain to Level Acceptable to Patient *
Reduce Pain to Level Acceptable to Patient proficiency* Reduce Pain to Level Acceptable to Patient frequency* WHO 3-Step Ladder *
WHO 3-Step Ladder proficiency* WHO 3-Step Ladder frequency* Non - Pharmacological Management of Pain *
Non - Pharmacological Management of Pain proficiency* Non - Pharmacological Management of Pain frequency* Pharmacological Management of Pain *
Pharmacological Management of Pain proficiency* Pharmacological Management of Pain frequency* Effects of Pharmacological Treatment *
Effects of Pharmacological Treatment proficiency* Effects of Pharmacological Treatment frequency* Nociceptive / Neuropathic / Mixed Pain *
Nociceptive / Neuropathic / Mixed Pain proficiency* Nociceptive / Neuropathic / Mixed Pain frequency* Management of Nociceptive Pain *
Management of Nociceptive Pain proficiency* Management of Nociceptive Pain frequency* Management of Neuropathic Pain *
Management of Neuropathic Pain proficiency* Management of Neuropathic Pain frequency* Educate Family on Pain Management *
Educate Family on Pain Management proficiency* Educate Family on Pain Management frequency*
Wound Care
Proficiency Rating
Frequency Rating
Positioning Techniques *
Positioning Techniques proficiency* Positioning Techniques frequency* Bed / Support Surface Selection *
Bed / Support Surface Selection proficiency* Bed / Support Surface Selection frequency* Pressure Ulcer Staging / Management *
Pressure Ulcer Staging / Management proficiency* Pressure Ulcer Staging / Management frequency* Response to Treatment *
Response to Treatment proficiency* Response to Treatment frequency* Evaluate Factors that Impede Healing *
Evaluate Factors that Impede Healing proficiency* Evaluate Factors that Impede Healing frequency* Educate Family on Positioning / Shearing *
Educate Family on Positioning / Shearing proficiency* Educate Family on Positioning / Shearing frequency*
Pediatrics
Proficiency Rating
Frequency Rating
Developmentally Appropriate Assessment *
Developmentally Appropriate Assessment proficiency* Developmentally Appropriate Assessment frequency* Parental / Sibling Support *
Parental / Sibling Support proficiency* Parental / Sibling Support frequency* Pediatric Support Team Collaboration *
Pediatric Support Team Collaboration proficiency* Pediatric Support Team Collaboration frequency*
Medication Administration
Proficiency Rating
Frequency Rating
Equianalgesic Conversion Formula *
Equianalgesic Conversion Formula proficiency* Equianalgesic Conversion Formula frequency* Titration of Opioids *
Titration of Opioids proficiency* Titration of Opioids frequency* IV Pump Management *
IV Pump Management proficiency* IV Pump Management frequency* Evaluate Effectiveness of Medications *
Evaluate Effectiveness of Medications proficiency* Evaluate Effectiveness of Medications frequency* Family Management of Medications *
Family Management of Medications proficiency* Family Management of Medications frequency* Disposal of Medications *
Disposal of Medications proficiency* Disposal of Medications frequency*
After Death
Proficiency Rating
Frequency Rating
Family / Cultural Rituals / Rites *
Family / Cultural Rituals / Rites proficiency* Family / Cultural Rituals / Rites frequency* Patient Care after Death *
Patient Care after Death proficiency* Patient Care after Death frequency* Coordinate Mortuary Services *
Coordinate Mortuary Services proficiency* Coordinate Mortuary Services frequency* Bereavement Services *
Bereavement Services proficiency* Bereavement Services frequency*
Compliance
Proficiency Rating
Frequency Rating
Scope and Frequency of Services *
Scope and Frequency of Services proficiency* Scope and Frequency of Services frequency* Medicare / State Regulations for Hospice *
Medicare / State Regulations for Hospice proficiency* Medicare / State Regulations for Hospice frequency* Document Progression of Decline *
Document Progression of Decline proficiency* Document Progression of Decline frequency* DME Authorization & Documentation of Need / Order *
DME Authorization & Documentation of Need / Order proficiency* DME Authorization & Documentation of Need / Order frequency* OASIS-C *
OASIS-C proficiency* OASIS-C frequency*
Professional Knowledge and Skills
Proficiency Rating
Frequency Rating
Identify Source of Suffering *
Identify Source of Suffering proficiency* Identify Source of Suffering frequency* Palliative Care Philosophy *
Palliative Care Philosophy proficiency* Palliative Care Philosophy frequency* Patient / Family Directs Goals of Care *
Patient / Family Directs Goals of Care proficiency* Patient / Family Directs Goals of Care frequency* Maximize Quality of Life *
Maximize Quality of Life proficiency* Maximize Quality of Life frequency* Cultural Diversity *
Cultural Diversity proficiency* Cultural Diversity frequency* Supervision of Ancillary Staff *
Supervision of Ancillary Staff proficiency* Supervision of Ancillary Staff frequency* National Patient Safety Goals / Core Measures *
National Patient Safety Goals / Core Measures proficiency* National Patient Safety Goals / Core Measures frequency* Fall Risk Assessment / Prevention *
Fall Risk Assessment / Prevention proficiency* Fall Risk Assessment / Prevention frequency* Infection Prevention *
Infection Prevention proficiency* Infection Prevention frequency* Isolation Precautions *
Isolation Precautions proficiency* Isolation Precautions frequency* Interpretation and Communication of Lab Values *
Interpretation and Communication of Lab Values proficiency* Interpretation and Communication of Lab Values frequency* Electronic Documentation *
Electronic Documentation proficiency* Electronic Documentation frequency* Automated Med Dispensing Systems *
Automated Med Dispensing Systems proficiency* Automated Med Dispensing Systems frequency* Certify your information* I certify that I have provided true and accurate information about my skills and experience to the best of my ability
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