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*
Leadership
Proficiency Rating
Frequency Rating
Communicates effectively with residents, families, significant others, and other team members *
Communicates effectively with residents, families, significant others, and other team members proficiency* Communicates effectively with residents, families, significant others, and other team members frequency* Communicates effectively with peers, physicians, and State agencies *
Communicates effectively with peers, physicians, and State agencies proficiency* Communicates effectively with peers, physicians, and State agencies frequency* Coordinates resident care to the multidisciplinary team via meetings *
Coordinates resident care to the multidisciplinary team via meetings proficiency* Coordinates resident care to the multidisciplinary team via meetings frequency* Provides updated resident information to physicians, resident, family, legal, consultants, State agencies in accordance with regulations and/or standards *
Provides updated resident information to physicians, resident, family, legal, consultants, State agencies in accordance with regulations and/or standards proficiency* Provides updated resident information to physicians, resident, family, legal, consultants, State agencies in accordance with regulations and/or standards frequency* Knowledgeable and able to execute human recourse policies as applicable to a variety of people issues *
Knowledgeable and able to execute human recourse policies as applicable to a variety of people issues proficiency* Knowledgeable and able to execute human recourse policies as applicable to a variety of people issues frequency* Delegates as appropriate *
Delegates as appropriate proficiency* Delegates as appropriate frequency* Actions demonstrate excellent customer service skills and builds relationships with families and associates *
Actions demonstrate excellent customer service skills and builds relationships with families and associates proficiency* Actions demonstrate excellent customer service skills and builds relationships with families and associates frequency* Monitors the progress of others *
Monitors the progress of others proficiency* Monitors the progress of others frequency* Enforces regulatory and employee law compliance *
Enforces regulatory and employee law compliance proficiency* Enforces regulatory and employee law compliance frequency*
Technical
Proficiency Rating
Frequency Rating
Assesses and monitor staff compliance of infection control and safety programs *
Assesses and monitor staff compliance of infection control and safety programs proficiency* Assesses and monitor staff compliance of infection control and safety programs frequency* Demonstrates excellent technical skills and judgement *
Demonstrates excellent technical skills and judgement proficiency* Demonstrates excellent technical skills and judgement frequency* Assesses and monitors accuracy of Facility Scorecard and CMS quality indicator date and initiates corrective action as indicated *
Assesses and monitors accuracy of Facility Scorecard and CMS quality indicator date and initiates corrective action as indicated proficiency* Assesses and monitors accuracy of Facility Scorecard and CMS quality indicator date and initiates corrective action as indicated frequency* Actively participates and contributes to facility meetings and process improvement activities *
Actively participates and contributes to facility meetings and process improvement activities proficiency* Actively participates and contributes to facility meetings and process improvement activities frequency* Promotes survey preparedness at all times *
Promotes survey preparedness at all times proficiency* Promotes survey preparedness at all times frequency* Demonstrates basic working knowledge of computer and modules and management reports *
Demonstrates basic working knowledge of computer and modules and management reports proficiency* Demonstrates basic working knowledge of computer and modules and management reports frequency* Demonstrates basic understanding of quality event investigating and reporting process *
Demonstrates basic understanding of quality event investigating and reporting process proficiency* Demonstrates basic understanding of quality event investigating and reporting process frequency* Maintains a current knowledge of LTC Federal and state regulations including Medicare, Medicaid, and JCAHO as applicable *
Maintains a current knowledge of LTC Federal and state regulations including Medicare, Medicaid, and JCAHO as applicable proficiency* Maintains a current knowledge of LTC Federal and state regulations including Medicare, Medicaid, and JCAHO as applicable frequency* Ensure that RAI functions are completed timely for all residents *
Ensure that RAI functions are completed timely for all residents proficiency* Ensure that RAI functions are completed timely for all residents frequency* Provides and monitors the effectiveness of clinical orientation and ongoing training to all associates *
Provides and monitors the effectiveness of clinical orientation and ongoing training to all associates proficiency* Provides and monitors the effectiveness of clinical orientation and ongoing training to all associates frequency*
Problem Solving
Proficiency Rating
Frequency Rating
Utilizes the nursing process to structure care to individual residents needs *
Utilizes the nursing process to structure care to individual residents needs proficiency* Utilizes the nursing process to structure care to individual residents needs frequency* Demonstrates the ability to assess and interpret data about the residents status and ensure timely interventions are executed *
Demonstrates the ability to assess and interpret data about the residents status and ensure timely interventions are executed proficiency* Demonstrates the ability to assess and interpret data about the residents status and ensure timely interventions are executed frequency* Collaborates with DNS/ Consultants on identified areas of noncompliance and implements necessary corrective actions *
Collaborates with DNS/ Consultants on identified areas of noncompliance and implements necessary corrective actions proficiency* Collaborates with DNS/ Consultants on identified areas of noncompliance and implements necessary corrective actions frequency* Effectively troubleshoots and ensures allocation of staffing resources to meet the needs of the residents *
Effectively troubleshoots and ensures allocation of staffing resources to meet the needs of the residents proficiency* Effectively troubleshoots and ensures allocation of staffing resources to meet the needs of the residents frequency* Demonstrates understanding of census as it relates to HOL, expense control, and budgeted PPD *
Demonstrates understanding of census as it relates to HOL, expense control, and budgeted PPD proficiency* Demonstrates understanding of census as it relates to HOL, expense control, and budgeted PPD frequency* Assesses and monitors discharge, rehospitalization patterns and implements corrective action as indicated *
Assesses and monitors discharge, rehospitalization patterns and implements corrective action as indicated proficiency* Assesses and monitors discharge, rehospitalization patterns and implements corrective action as indicated frequency*
Professional Knowledge And Skills
Proficiency Rating
Frequency Rating
National Patient Safety Goals *
National Patient Safety Goals proficiency* National Patient Safety Goals frequency* Age Specific Care *
Age Specific Care proficiency* Age Specific Care frequency* Population Based Care *
Population Based Care proficiency* Population Based Care frequency* Electronic Documentation *
Electronic Documentation proficiency* Electronic Documentation 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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