Ambulatory 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

Standard Precautions *

Standard Precautions proficiency*

Standard Precautions frequency*

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Adult Respiratory/ Cardiac Arrest *

Adult Respiratory/ Cardiac Arrest proficiency*

Adult Respiratory/ Cardiac Arrest frequency*

Pediatric Respiratory/Cardiac Arrest *

Pediatric Respiratory/Cardiac Arrest proficiency*

Pediatric Respiratory/Cardiac Arrest frequency*

Crash Carts *

Crash Carts proficiency*

Crash Carts frequency*

Defibrillators *

Defibrillators proficiency*

Defibrillators frequency*

Patient / Family Education *

Patient / Family Education proficiency*

Patient / Family Education frequency*

Admit and Assess Patients *

Admit and Assess Patients proficiency*

Admit and Assess Patients frequency*

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:

Obtaining Cultures (Blood, Sputum, Swab, Urine) *

Obtaining Cultures (Blood, Sputum, Swab, Urine) proficiency*

Obtaining Cultures (Blood, Sputum, Swab, Urine) frequency*

Advance Directives *

Advance Directives proficiency*

Advance Directives frequency*

Collect Appropriate Data *

Collect Appropriate Data proficiency*

Collect Appropriate Data frequency*

Discharge Teaching *

Discharge Teaching proficiency*

Discharge Teaching frequency*

Preoperative Teaching *

Preoperative Teaching proficiency*

Preoperative Teaching frequency*

Patient Prep *

Patient Prep proficiency*

Patient Prep frequency*

Cardiovascular

Proficiency Rating

Frequency Rating

Assess Heart Tones *

Assess Heart Tones proficiency*

Assess Heart Tones frequency*

Bedside Tele Monitoring *

Bedside Tele Monitoring proficiency*

Bedside Tele Monitoring frequency*

Interpretation of Coagulation Studies *

Interpretation of Coagulation Studies proficiency*

Interpretation of Coagulation Studies frequency*

Perform Pulse/ Circulation Checks *

Perform Pulse/ Circulation Checks proficiency*

Perform Pulse/ Circulation Checks frequency*

Pre-Post Op Pacemaker Care *

Pre-Post Op Pacemaker Care proficiency*

Pre-Post Op Pacemaker Care frequency*

Pulmonary

Proficiency Rating

Frequency Rating

Assess Breath Sounds *

Assess Breath Sounds proficiency*

Assess Breath Sounds frequency*

Apply Oxygen *

Apply Oxygen proficiency*

Apply Oxygen frequency*

Interpret ABGs *

Interpret ABGs proficiency*

Interpret ABGs frequency*

Thoracentesis *

Thoracentesis proficiency*

Thoracentesis frequency*

Oximetry *

Oximetry proficiency*

Oximetry frequency*

Neurology

Proficiency Rating

Frequency Rating

Assess Neurological Signs *

Assess Neurological Signs proficiency*

Assess Neurological Signs frequency*

Epidurals *

Epidurals proficiency*

Epidurals frequency*

Selective Nerve Root Blocks *

Selective Nerve Root Blocks proficiency*

Selective Nerve Root Blocks frequency*

Assess Level of Consciousness *

Assess Level of Consciousness proficiency*

Assess Level of Consciousness frequency*

Proficiency Rating

Frequency Rating

Insertion / Monitoring NG Tubes *

Insertion / Monitoring NG Tubes proficiency*

Insertion / Monitoring NG Tubes frequency*

Assessment *

Assessment proficiency*

Assessment frequency*

Flexible Sigmoidoscopy *

Flexible Sigmoidoscopy proficiency*

Flexible Sigmoidoscopy frequency*

Hemorrhoid Banding *

Hemorrhoid Banding proficiency*

Hemorrhoid Banding frequency*

Liver Biopsy *

Liver Biopsy proficiency*

Liver Biopsy frequency*

Paracentesis *

Paracentesis proficiency*

Paracentesis frequency*

Lap Band Surgery *

Lap Band Surgery proficiency*

Lap Band Surgery frequency*

Proficiency Rating

Frequency Rating

Bladder Biopsy *

Bladder Biopsy proficiency*

Bladder Biopsy frequency*

Cystoscopy *

Cystoscopy proficiency*

Cystoscopy frequency*

Urethral Dilation *

Urethral Dilation proficiency*

Urethral Dilation frequency*

Nephrostomy *

Nephrostomy proficiency*

Nephrostomy frequency*

Kidney Biopsy *

Kidney Biopsy proficiency*

Kidney Biopsy frequency*

Suprapubic Catheter *

Suprapubic Catheter proficiency*

Suprapubic Catheter frequency*

Prostate Biopsy *

Prostate Biopsys proficiency*

Prostate Biopsy frequency*

Endocrine

Proficiency Rating

Frequency Rating

Care of Diabetic Patient *

Care of Diabetic Patient proficiency*

Care of Diabetic Patient frequency*

Diabetic Teaching *

Diabetic Teaching proficiency*

Diabetic Teaching frequency*

Blood Glucose Testing *

Blood Glucose Testing proficiency*

Blood Glucose Testing frequency*

Ent & Mouth

Proficiency Rating

Frequency Rating

Prosthodontics - Restorative Dentistry *

Prosthodontics - Restorative Dentistry proficiency*

Prosthodontics - Restorative Dentistry frequency*

Mouth Biopsy *

Mouth Biopsy proficiency*

Mouth Biopsy frequency*

Myringotomy *

Myringotomy proficiency*

Myringotomy frequency*

Maxillofacial Prosthetics *

Maxillofacial Prosthetics proficiency*

Maxillofacial Prosthetics frequency*

Nose Biopsy *

Nose Biopsy proficiency*

Nose Biopsy frequency*

Thyroid Aspirate Biopsy *

Thyroid Aspirate Biopsy proficiency*

Thyroid Aspirate Biopsy frequency*

Fiberoptic Laryngoscopy *

Fiberoptic Laryngoscopy proficiency*

Fiberoptic Laryngoscopy frequency*

Tonsillectomy *

Tonsillectomy proficiency*

Tonsillectomy frequency*

Wounds / Integument

Proficiency Rating

Frequency Rating

Application of Burn Dressing *

Application of Burn Dressing proficiency*

Application of Burn Dressing frequency*

Dressing Changes *

Dressing Changes proficiency*

Dressing Changes frequency*

Debridement of Wound *

Debridement of Wound proficiency*

Debridement of Wound frequency*

Wound Care *

Wound Care proficiency*

Wound Care frequency*

Wound Vac *

Wound Vac proficiency*

Wound Vac frequency*

OB / GYN

Proficiency Rating

Frequency Rating

Electrodesiccation and Curettage (ED7C) *

Electrodesiccation and Curettage (ED7C) proficiency*

Electrodesiccation and Curettage (ED7C) frequency*

Assist with In-Office Procedures *

Assist with In-Office Procedures proficiency*

Assist with In-Office Procedures frequency*

Ortho

Proficiency Rating

Frequency Rating

Arthrocentesis *

Arthrocentesis proficiency*

Arthrocentesis frequency*

External Hardware and Pin Care *

External Hardware and Pin Care proficiency*

External Hardware and Pin Care frequency*

Arthroscopy *

Arthroscopy proficiency*

Arthroscopy frequency*

Open Reduction and Internal Fixation *

Open Reduction and Internal Fixation proficiency*

Open Reduction and Internal Fixation frequency*

Closed Reduction and Internal Fixation *

Closed Reduction and Internal Fixation proficiency*

Closed Reduction and Internal Fixation frequency*

Trigger Point Injections *

Trigger Point Injections proficiency*

Trigger Point Injections frequency*

Plastics

Proficiency Rating

Frequency Rating

Rhinoplasty *

Rhinoplasty proficiency*

Rhinoplasty frequency*

Liposuction *

Liposuction proficiency*

Liposuction frequency*

Nipple Reconstruction *

Nipple Reconstruction proficiency*

Nipple Reconstruction frequency*

MOHS Repairs *

MOHS Repairs proficiency*

MOHS Repairs frequency*

Blepharoplasty *

Blepharoplasty proficiency*

Blepharoplasty frequency*

Mole / Cyst Removal *

Mole / Cyst Removal proficiency*

Mole / Cyst Removal frequency*

General Medications / Therapeutic Interventions

Proficiency Rating

Frequency Rating

Administer IM and SQ Medications *

Administer IM and SQ Medications proficiency*

Administer IM and SQ Medications frequency*

Administer Inhalation Medications *

Administer Inhalation Medications proficiency*

Administer Inhalation Medications frequency*

Administer PO Medications *

Administer PO Medications proficiency*

Administer PO Medications frequency*

Bladder Irrigation and Installation *

Bladder Irrigation and Installation proficiency*

Bladder Irrigation and Installation frequency*

Needleless System *

Needleless System proficiency*

Needleless System frequency*

Chemotherapy *

Chemotherapy proficiency*

Chemotherapy frequency*

IV Therapy

Proficiency Rating

Frequency Rating

Infusion Pumps *

Infusion Pumps proficiency*

Infusion Pumps frequency*

Peripheral IV Insertion *

Peripheral IV Insertion proficiency*

Peripheral IV Insertion frequency*

Syringe Pumps *

Syringe Pumps proficiency*

Syringe Pumps frequency*

Vascular Access Devices Care/ Maintenance *

Vascular Access Devices Care/ Maintenance proficiency*

Vascular Access Devices Care/ Maintenance frequency*

Administer IV Medications *

Administer IV Medications proficiency*

Administer IV Medications frequency*

Oxygen Administration

Proficiency Rating

Frequency Rating

Ambu-Bag *

Ambu-Bag proficiency*

Ambu-Bag frequency*

Nasal Cannula *

Nasal Cannula proficiency*

Nasal Cannula frequency*

Non-Rebreather Mask *

Non-Rebreather Mask proficiency*

Non-Rebreather Mask frequency*

Venti Mask *

Venti Mask proficiency*

Venti Masks frequency*

Face Mask *

Face Mask proficiency*

Face Mask frequency*

Nutritional Therapy

Proficiency Rating

Frequency Rating

Lipids *

Lipids proficiency*

Lipids frequency*

TPN *

TPN proficiency*

TPN frequency*

Procalamine *

Procalamine proficiency*

Procalamine frequency*

Enteral Administration *

Enteral Administration proficiency*

Enteral Administration frequency*

Pain Management / Anesthesia

Proficiency Rating

Frequency Rating

Implantable Narcotic Pump *

Implantable Narcotic Pump proficiency*

Implantable Narcotic Pump frequency*

Moderate Sedation *

Moderate Sedation proficiency*

Moderate Sedation frequency*

Epidural *

Epidural proficiency*

Epidural frequency*

Spinal *

Spinal proficiency*

Spinal frequency*

Local *

Local proficiency*

Local frequency*

General *

General proficiency*

General frequency*

Axillary Block *

Axillary Block proficiency*

Axillary Block frequency*

Bier Block *

Bier Block proficiency*

Bier Block frequency*

General Procedures / Equipment

Proficiency Rating

Frequency Rating

Apply Immobilizers (clavicle, knee, etc.) *

Apply Immobilizers (clavicle, knee, etc.) proficiency*

Apply Immobilizers (clavicle, knee, etc.) frequency*

Assist with Code Resuscitation *

Assist with Code Resuscitation proficiency*

Assist with Code Resuscitation frequency*

Assist with Lumbar Puncture *

Assist with Lumbar Puncture proficiency*

Assist with Lumbar Puncture frequency*

Laser *

Laser proficiency*

Laser frequency*

Dermabrasion *

Dermabrasion proficiency*

Dermabrasion frequency*

Drain Removal *

Drain Removal proficiency*

Drain Removal frequency*

Incision and Drainage *

Incision and Drainage proficiency*

Incision and Drainage frequency*

NGT Insertion *

NGT Insertion proficiency*

NGT Insertion frequency*

Patch Test *

Patch Test proficiency*

Patch Test frequency*

Punch Biopsy *

Punch Biopsy proficiency*

Punch Biopsy frequency*

Shave Biopsy *

Shave Biopsy proficiency*

Shave Biopsy frequency*

Procedure Set Up *

Procedure Set Up proficiency*

Procedure Set Up frequency*

Remove External Fixators with Pin *

Remove External Fixators with Pin proficiency*

Remove External Fixators with Pin frequency*

Scrub *

Scrub proficiency*

Scrub frequency*

Screw-Hardware Removal *

Screw-Hardware Removal proficiency*

Screw-Hardware Removal frequency*

Set-Up / Assist Suturing *

Set-Up / Assist Suturing proficiency*

Set-Up / Assist Suturing frequency*

Staple Removal *

Staple Removal proficiency*

Staple Removal frequency*

Suture Removal *

Suture Removal proficiency*

Suture Removal frequency*

Foley/ Straight Catheter - Male *

Foley/ Straight Catheter - Male proficiency*

Foley/ Straight Catheter - Male frequency*

Foley/ Straight Catheter - Female *

Foley/ Straight Catheter - Female proficiency*

Foley/ Straight Catheter - Female frequency*

TENS Unit *

TENS Unit proficiency*

TENS Unit frequency*

Use of Doppler *

Use of Doppler proficiency*

Use of Doppler frequency*

Specimen Collections

Proficiency Rating

Frequency Rating

Venipuncture *

Venipuncture proficiency*

Venipuncture frequency*

Clean Catch Urine *

Clean Catch Urine proficiency*

Clean Catch Urine frequency*

Sterile Urine Collection *

Sterile Urine Collection proficiency*

Sterile Urine Collection frequency*

Stool *

Stool proficiency*

Stool frequency*

Sputum *

Sputum proficiency*

Sputum frequency*

Butterfly Stick *

Butterfly Stick proficiency*

Butterfly Stick frequency*

Central Line Draw *

Central Line Draw proficiency*

Central Line Draw frequency*

Clinical Settings

Proficiency Rating

Frequency Rating

Surgi-Center *

Surgi-Center proficiency*

Surgi-Center frequency*

Out Patient Clinic *

Out Patient Clinic proficiency*

Out Patient Clinic frequency*

Physician Office *

Physician Office proficiency*

Physician Office frequency*

Ambulatory Surgery Clinic *

Ambulatory Surgery Clinic proficiency*

Ambulatory Surgery Clinic frequency*

Other Skills:

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Date*

Skills/Competences

Proficiency

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AMBULATORY RN

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