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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

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Pediatric Respiratory / Cardiac Arrest *

Pediatric Respiratory / Cardiac Arrest proficiency*

Pediatric Respiratory / Cardiac Arrest frequency*

Adult Respiratory / Cardiac Arrest *

Adult Respiratory / Cardiac Arrest proficiency*

Adult Respiratory / Cardiac Arrest frequency*

Crash Carts *

Crash Carts proficiency*

Crash Carts frequency*

Defibrillators *

Defibrillators proficiency*

Defibrillators frequency*

Care of Patient in Restraints *

Care of Patient in Restraints proficiency*

Care of Patient in Restraints 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:

Care Planning & Discharge Planning *

Care Planning & Discharge Planning proficiency*

Care Planning & Discharge Planning frequency*

Patient / Family Education *

Patient / Family Education proficiency*

Patient / Family Education frequency*

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Patient Head to Toe Assessment *

Patient Head to Toe Assessment proficiency*

Patient Head to Toe Assessment frequency*

Peripheral IV Insertion, Care and Maintenance *

Peripheral IV Insertion, Care and Maintenance proficiency*

Peripheral IV Insertion, Care and Maintenance frequency*

Triage Procedures *

Triage Procedures proficiency*

Triage Procedures frequency*

Lab Values *

Lab Values proficiency*

Lab Values frequency*

Procedure for Patient Signing AMA *

Procedure for Patient Signing AMA proficiency*

Procedure for Patient Signing AMA frequency*

Consent for Treatment of Minor *

Consent for Treatment of Minor proficiency*

Consent for Treatment of Minor frequency*

Disaster Protocols *

Disaster Protocols proficiency*

Disaster Protocols frequency*

Crisis Intervention *

Crisis Intervention proficiency*

Crisis Intervention frequency*

Upholding Patient’s Rights *

Upholding Patient’s Rights proficiency*

Upholding Patient’s Rights frequency*

Reporting Procedures for Acts of Violence *

Reporting Procedures for Acts of Violence proficiency*

Reporting Procedures for Acts of Violence frequency*

Care of Patients with Infectious Diseases *

Care of Patients with Infectious Diseases proficiency*

Care of Patients with Infectious Diseases frequency*

Care of Patient with Central Line *

Care of Patient with Central Line proficiency*

Care of Patient with Central Line frequency*

Immunocompromised

Proficiency Rating

Frequency Rating

Care of Patients with Cancer *

Care of Patients with Cancer proficiency*

Care of Patients with Cancer frequency*

Care of Patients with HIV / AIDS *

Care of Patients with HIV / AIDS proficiency*

Care of Patients with HIV / AIDS frequency*

Care of Patients with Hepatitis *

Care of Patients with Hepatitis proficiency*

Care of Patients with Hepatitis frequency*

Care of Patients with TB *

Care of Patients with TB proficiency*

Care of Patients with TB frequency*

Heent Disorders - Care of patients with:

Proficiency Rating

Frequency Rating

Set-up for Lamp Exam *

Set-up for Lamp Exam proficiency*

Set-up for Lamp Exam frequency*

Use of Morgan Lens Irrigation *

Use of Morgan Lens Irrigation proficiency*

Use of Morgan Lens Irrigation frequency*

Ear Irrigations *

Ear Irrigations proficiency*

Ear Irrigations frequency*

Eye Irrigations *

Eye Irrigations proficiency*

Eye Irrigations frequency*

Eye Patch Application *

Eye Patch Application proficiency*

Eye Patch Application frequency*

Epistaxis / Nasal Packing *

Epistaxis / Nasal Packing proficiency*

Epistaxis / Nasal Packing frequency*

Visual Acuity *

Visual Acuity proficiency*

Visual Acuity frequency*

Pulmonary - Care of patients with:

Proficiency Rating

Frequency Rating

Pulmonary Edema *

Pulmonary Edema proficiency*

Pulmonary Edema frequency*

Pulmonary Embolism *

Pulmonary Embolism proficiency*

Pulmonary Embolism frequency*

ARDS *

ARDS proficiency*

ARDS frequency*

Trach *

Trach proficiency*

Trach frequency*

COPD *

COPD proficiency*

COPD frequency*

Aspiration *

Aspiration proficiency*

Aspiration frequency*

Tuberculosis *

Tuberculosis proficiency*

Tuberculosis frequency*

Pneumothorax *

Pneumothorax proficiency*

Pneumothorax frequency*

Intubation / Extubation *

Intubation / Extubation proficiency*

Intubation / Extubation frequency*

T-Piece *

T-Piece proficiency*

T-Piece frequency*

Obtaining Arterial Blood GasesLithotripsy *

Obtaining Arterial Blood Gases proficiency*

Obtaining Arterial Blood Gases frequency*

Setting Up of Arterial Line *

Setting Up of Arterial Line proficiency*

Setting Up of Arterial Line frequency*

Ventilator *

Ventilator proficiency*

Ventilator frequency*

O2 Mask and Cannula *

O2 Mask and Cannula proficiency*

O2 Mask and Cannula frequency*

O2 Cylinders *

O2 Cylinders proficiency*

O2 Cylinders frequency*

Nebulizer Set-Up *

Nebulizer Set-Up proficiency*

Nebulizer Set-Up frequency*

Oropharyngeal Suction *

Oropharyngeal Suction proficiency*

Oropharyngeal Suction frequency*

Nasotracheal Suction *

Nasotracheal Suction proficiency*

Nasotracheal Suction frequency*

Endotracheal Suction *

Endotracheal Suction proficiency*

Endotracheal Suction frequency*

Assisting with Chest Tube Insertion *

Assisting with Chest Tube Insertion proficiency*

Assisting with Chest Tube Insertion frequency*

Use of Pleuravac Drainage System *

Use of Pleuravac Drainage System proficiency*

Use of Pleuravac Drainage System frequency*

Use of Emerson Drainage System *

Use of Emerson Drainage System proficiency*

Use of Emerson Drainage System frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Bronchodilators *

Bronchodilators proficiency*

Bronchodilators frequency*

Racemic Epinephrine *

Racemic Epinephrine proficiency*

Racemic Epinephrine frequency*

Steroids (IV / PO / INHALED) *

Steroids (IV / PO / INHALED) proficiency*

Steroids (IV / PO / INHALED) frequency*

Cardiovascular - Care of patients with:

Proficiency Rating

Frequency Rating

Acute MI, Angina *

Acute MI, Angina proficiency*

Acute MI, Angina frequency*

CHF *

CHF proficiency*

CHF frequency*

Abdominal Aortic Aneurysm *

Abdominal Aortic Aneurysm proficiency*

Abdominal Aortic Aneurysm frequency*

Cardiac Monitoring *

Cardiac Monitoring proficiency*

Cardiac Monitoring frequency*

Recognizing Arrhythmias *

Recognizing Arrhythmias proficiency*

Recognizing Arrhythmias frequency*

Obtaining 12 Lead EKG’s *

Obtaining 12 Lead EKG’s proficiency*

Obtaining 12 Lead EKG’s frequency*

Cardioversion *

Cardioversion proficiency*

Cardioversion frequency*

Open Chest Heart Massage *

Open Chest Heart Massage proficiency*

Open Chest Heart Massage frequency*

Assist with Insertion of Pacemakers (Temp / Perm) *

Assist with Insertion of Pacemakers (Temp / Perm) proficiency*

Assist with Insertion of Pacemakers (Temp / Perm) frequency*

Set-up & Use of CVP *

Set-up & Use of CVP proficiency*

Set-up & Use of CVP frequency*

Interpretation of CVP Readings *

Interpretation of CVP Readings proficiency*

Interpretation of CVP Readings frequency*

Interpretation of Swan-Ganz Readings *

Interpretation of Swan-Ganz Readings proficiency*

Interpretation of Swan-Ganz Readings frequency*

Thrombolytic Therapy *

Thrombolytic Therapy proficiency*

Thrombolytic Therapy frequency*

Anaphylactic Shock *

Anaphylactic Shock proficiency*

Anaphylactic Shock frequency*

Cardiogenic Shock *

Cardiogenic Shock proficiency*

Cardiogenic Shock frequency*

Septic Shock *

Septic Shock proficiency*

Septic Shock frequency*

Hypovolemic Shock *

Hypovolemic Shock proficiency*

Hypovolemic Shock frequency*

Administration of Blood and Blood Products *

Administration of Blood and Blood Products proficiency*

Administration of Blood and Blood Products frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Heparin *

Heparin proficiency*

Heparin frequency*

Sodium Bicarbonate *

Sodium Bicarbonate proficiency*

Sodium Bicarbonate frequency*

Lidocaine *

Lidocaine proficiency*

Lidocaine frequency*

Bretylium *

Bretylium proficiency*

Bretylium frequency*

Nipride *

Nipride proficiency*

Nipride frequency*

Dopamine *

Dopamine proficiency*

Dopamine frequency*

Isuprel *

Isuprel proficiency*

Isuprel frequency*

Digitalis *

Digitalis proficiency*

Digitalis frequency*

Atropine *

Atropine proficiency*

Atropine frequency*

Epinephrine *

Epinephrine proficiency*

Epinephrine frequency*

Dobutrex *

Dobutrex proficiency*

Dobutrex frequency*

Tridil / Nitroglycerine *

Tridil / Nitroglycerine proficiency*

Tridil / Nitroglycerine frequency*

Neurological - Care of patients with:

Proficiency Rating

Frequency Rating

Spinal Precautions *

Spinal Precautions proficiency*

Spinal Precautions frequency*

Neuro Assessment *

Neuro Assessment proficiency*

Neuro Assessment frequency*

Use of Glasgow Coma Scale *

Use of Glasgow Coma Scale proficiency*

Use of Glasgow Coma Scale frequency*

Acute Head Injury *

Acute Head Injury proficiency*

Acute Head Injury frequency*

Acute T.I.A. / C.V.A *

Acute T.I.A. / C.V.A proficiency*

Acute T.I.A. / C.V.A frequency*

Acute Spinal Cord Injury *

Acute Spinal Cord Injury proficiency*

Acute Spinal Cord Injury frequency*

Seizure Precautions *

Seizure Precautions proficiency*

Seizure Precautions frequency*

Observing for Increased Intracranial Pressure *

Observing for Increased Intracranial Pressure proficiency*

Observing for Increased Intracranial Pressure frequency*

Assist with Lumbar Puncture *

Assist with Lumbar Puncture proficiency*

Assist with Lumbar Puncture frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Narcan *

Narcan proficiency*

Narcan frequency*

Dilantin *

Dilantin proficiency*

Dilantin frequency*

Phenobarbital *

Phenobarbital proficiency*

Phenobarbital frequency*

Decadron *

Decadron proficiency*

Decadron frequency*

Mannitol *

Mannitol proficiency*

Mannitol frequency*

Solu-Medrol *

Solu-Medrol proficiency*

Solu-Medrol frequency*

Gastrointenstinal - Care of patients with:

Proficiency Rating

Frequency Rating

G.I. Bleed *

G.I. Bleed proficiency*

G.I. Bleed frequency*

Abdominal Wounds *

Abdominal Wounds proficiency*

Abdominal Wounds frequency*

Acute Abdominal Disorders *

Acute Abdominal Disorders proficiency*

Acute Abdominal Disorders frequency*

Insertion of Nasogastric Tube *

Insertion of Nasogastric Tube proficiency*

Insertion of Nasogastric Tube frequency*

Gastric Lavage *

Gastric Lavage proficiency*

Gastric Lavage frequency*

Renal - Care of patients with:

Proficiency Rating

Frequency Rating

Renal Failure *

Renal Failure proficiency*

Renal Failure frequency*

Peritoneal Dialysis *

Peritoneal Dialysis proficiency*

Peritoneal Dialysis frequency*

Renal Calculi *

Renal Calculi proficiency*

Renal Calculi frequency*

Pyelonephritis / UTI *

Pyelonephritis / UTI proficiency*

Pyelonephritis / UTI frequency*

Obstetrics / Gynecology - Care of patients with:

Proficiency Rating

Frequency Rating

HELLP Syndrome *

HELLP Syndrome proficiency*

HELLP Syndrome frequency*

Spontaneous Abortion *

Spontaneous Abortion proficiency*

Spontaneous Abortion frequency*

Hemorrhage *

Hemorrhage proficiency*

Hemorrhage frequency*

Placenta Previa *

Placenta Previa proficiency*

Placenta Previa frequency*

Placental Abruption *

Placental Abruption proficiency*

Placental Abruption frequency*

Pre-eclampsia / Eclampsia *

Pre-eclampsia / Eclampsia proficiency*

Pre-eclampsia / Eclampsia frequency*

Emergency Delivery *

Emergency Delivery proficiency*

Emergency Delivery frequency*

Fetal Heart Tones *

Fetal Heart Tones proficiency*

Fetal Heart Tones frequency*

Sexually Transmitted Disease *

Sexually Transmitted Disease proficiency*

Sexually Transmitted Disease frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Pitocin *

Pitocin proficiency*

Pitocin frequency*

Magnesium Sulfate *

Magnesium Sulfate proficiency*

Magnesium Sulfate frequency*

Psychiatric - Care of patients with:

Proficiency Rating

Frequency Rating

Suicidal Patient *

Suicidal Patient proficiency*

Suicidal Patient frequency*

Overdose *

Overdose proficiency*

Overdose frequency*

Emergency Police Hold *

Emergency Police Hold proficiency*

Emergency Police Hold frequency*

ETOH Abuse / DTs *

ETOH Abuse / DTs proficiency*

ETOH Abuse / DTs frequency*

Seclusion *

Seclusion proficiency*

Seclusion frequency*

Sexual Assault / Child Abuse - Care of patients with:

Proficiency Rating

Frequency Rating

Sexual Assault *

Sexual Assault proficiency*

Sexual Assault frequency*

Signs of Abuse *

Signs of Abuse proficiency*

Signs of Abuse frequency*

Orthopedic - Care of patients with:

Proficiency Rating

Frequency Rating

Traction *

Traction proficiency*

Traction frequency*

Cast Application *

Cast Application proficiency*

Cast Application frequency*

Checking C/M/S *

Checking C/M/S proficiency*

Checking C/M/S frequency*

OCL Splinting *

OCL Splinting proficiency*

OCL Splinting frequency*

Pins / Wires *

Pins / Wires proficiency*

Pins / Wires frequency*

Closed Fracture / Dislocation Reduction *

Closed Fracture / Dislocation Reduction proficiency*

Closed Fracture / Dislocation Reduction frequency*

Application of Orthopedic Appliances *

Application of Orthopedic Appliances proficiency*

Application of Orthopedic Appliances frequency*

Lacerations - Care of patients with:

Proficiency Rating

Frequency Rating

Setting up Suture Tray *

Setting up Suture Tray proficiency*

Setting up Suture Tray frequency*

Assist with Sutures / Staples *

Assist with Sutures / Staples proficiency*

Assist with Sutures / Staples frequency*

Steri Strips *

Steri Strips proficiency*

Steri Strips frequency*

Trauma - Care of patients with:

Proficiency Rating

Frequency Rating

Air Transport of Trauma Patient *

Air Transport of Trauma Patient proficiency*

Air Transport of Trauma Patient frequency*

Major Trauma *

Major Trauma proficiency*

Major Trauma frequency*

Minor Trauma *

Minor Trauma proficiency*

Minor Trauma frequency*

M.A.S.T. Suit *

M.A.S.T. Suit proficiency*

M.A.S.T. Suit frequency*

Burns - Care of patients with:

Proficiency Rating

Frequency Rating

First Degree *

First Degree proficiency*

First Degree frequency*

Second Degree *

Second Degree proficiency*

Second Degree frequency*

Third Degree *

Third Degree proficiency*

Third Degree frequency*

Electrocution *

Electrocution proficiency*

Electrocution frequency*

Hazardous Materials Exposure *

Hazardous Materials Exposure proficiency*

Hazardous Materials Exposure frequency*

Radiation Exposure *

Radiation Exposure proficiency*

Radiation Exposure frequency*

Pediatric General Skills:

Proficiency Rating

Frequency Rating

Abuse Reporting *

Abuse Reporting proficiency*

Abuse Reporting frequency*

Vital Sign Parameters for Pediatric Patients *

Vital Sign Parameters for Pediatric Patients proficiency*

Vital Sign Parameters for Pediatric Patients frequency*

Calculating Pediatric Medication Dosages *

Calculating Pediatric Medication Dosages proficiency*

Calculating Pediatric Medication Dosages frequency*

Knowledge of Normal Serum Lab Values *

Knowledge of Normal Serum Lab Values proficiency*

Knowledge of Normal Serum Lab Values frequency*

Pediatric - Care of patients with:

Proficiency Rating

Frequency Rating

Febrile Seizure *

Febrile Seizure proficiency*

Febrile Seizure frequency*

Epiglottitis *

Epiglottitis proficiency*

Epiglottitis frequency*

Overdose / Poison Ingestion *

Overdose / Poison Ingestion proficiency*

Overdose / Poison Ingestion frequency*

Asthma *

Asthma proficiency*

Asthma frequency*

Near Drowning *

Near Drowning proficiency*

Near Drowning frequency*

Environmental - Care of patients with::

Proficiency Rating

Frequency Rating

Hypothermia *

Hypothermia proficiency*

Hypothermia frequency*

Heat Stroke / Exhaustion *

Heat Stroke / Exhaustion proficiency*

Heat Stroke / Exhaustion frequency*

Snake Bite *

Snake Bite proficiency*

Snake Bite frequency*

Administration of Antivenom *

Administration of Antivenom proficiency*

Administration of Antivenom frequency*

Animal Bite *

Animal Bite proficiency*

Animal Bite frequency*

Poison Index *

Poison Index proficiency*

Poison Index frequency*

Knowledge and use of:

Proficiency Rating

Frequency Rating

Antibiotics *

Antibiotics proficiency*

Antibiotics frequency*

Analgesics *

Analgesics proficiency*

Analgesics frequency*

Antiemetics *

Antiemetics proficiency*

Antiemetics frequency*

Sedatives *

Sedatives proficiency*

Sedatives frequency*

Medication Titration and Calculations *

Medication Titration and Calculations proficiency*

Medication Titration and Calculations frequency*

Reversal Agents *

Reversal Agents proficiency*

Reversal Agents frequency*

Charcoal *

Charcoal proficiency*

Charcoal frequency*

Miscellaneous Instruments / Trays:

Proficiency Rating

Frequency Rating

Pelvic Tray *

Pelvic Tray proficiency*

Pelvic Tray frequency*

Cut Down Tray *

Cut Down Tray proficiency*

Cut Down Tray frequency*

Procto Tray *

Procto Tray proficiency*

Procto Tray frequency*

CVP Tray *

CVP Tray proficiency*

CVP Tray frequency*

Trach Tray *

Trach Tray proficiency*

Trach Tray frequency*

Culdocentesis Tray *

Culdocentesis Tray proficiency*

Culdocentesis Tray frequency*

Thoracentesis Tray *

Thoracentesis Tray proficiency*

Thoracentesis Tray frequency*

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Date*

Skills/Competences

Proficiency

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ER RN

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