Home Health LPN

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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*

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*

Defibrillators *

Defibrillators proficiency*

Defibrillators frequency*

Pain Management *

Pain Management proficiency*

Pain Management frequency*

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*

Cardiovascular

Proficiency Rating

Frequency Rating

ASSESSMENT

Angina *

Angina proficiency*

Angina frequency*

Apical Pulse Rate / Rhythm *

Apical Pulse Rate / Rhythm proficiency*

Apical Pulse Rate / Rhythm frequency*

Cardiac Auscultation (Rate, Rhythm) *

Cardiac Auscultation (Rate, Rhythm) proficiency*

Cardiac Auscultation (Rate, Rhythm) frequency*

Clinical Identification of Arrhythmias *

Clinical Identification of Arrhythmias proficiency*

Clinical Identification of Arrhythmias frequency*

Fluid Overload *

Fluid Overload proficiency*

Fluid Overload frequency*

Peripheral Pulses / Circulation Checks *

Peripheral Pulses / Circulation Checks proficiency*

Peripheral Pulses / Circulation Checks frequency*

INTERPRETATION OF LAB RESULTS:

PT / PTT / INR *

PT / PTT / INR proficiency*

PT / PTT / INR frequency*

Serum Electrolytes *

Serum Electrolytes proficiency*

Serum Electrolytes frequency*

EQUIPMENT & PROCEDURES:

Holter Monitor *

Holter Monitor proficiency*

Holter Monitor frequency*

Pacemaker / AID *

Pacemaker / AID proficiency*

Pacemaker / AID frequency*

CARE OF PATIENT WITH:

Hypotension *

Hypotension proficiency*

Hypotension frequency*

CAD / Post Myocardial Infarction (MI) *

CAD / Post Myocardial Infarction (MI) proficiency*

CAD / Post Myocardial Infarction (MI) frequency*

Congestive Heart Failure (CHF) *

Congestive Heart Failure (CHF) proficiency*

Congestive Heart Failure (CHF) frequency*

Fluid Retention *

Fluid Retention proficiency*

Fluid Retention frequency*

Hypertension *

Hypertension proficiency*

Hypertension frequency*

Pre / Post Cardiac Surgery *

Pre / Post Cardiac Surgery proficiency*

Pre / Post Cardiac Surgery frequency*

Pre / Post Vascular Surgery *

Pre / Post Vascular Surgery proficiency*

Pre / Post Vascular Surgery frequency*

MEDICATION ADMINISTRATION:

ACE Inhibitors *

ACE Inhibitors proficiency*

ACE Inhibitors frequency*

Anti - arrhythmic *

Anti - arrhythmic proficiency*

Anti - arrhythmic frequency*

Antibiotics *

Antibiotics proficiency*

Antibiotics frequency*

Anticoagulants *

Anticoagulants proficiency*

Anticoagulants frequency*

Antihypertensives *

Antihypertensives proficiency*

Antihypertensives frequency*

Antiplatelet Medications *

Antiplatelet Medications proficiency*

Antiplatelet Medications frequency*

Beta Blockers *

Beta Blockers proficiency*

Beta Blockers frequency*

Calcium Channel Blockers *

Calcium Channel Blockers proficiency*

Calcium Channel Blockers frequency*

Diuretics *

Diuretics proficiency*

Diuretics frequency*

Digoxin (Lanoxin) *

Digoxin (Lanoxin) proficiency*

Digoxin (Lanoxin) frequency*

Oral and Topical Nitrates *

Oral and Topical Nitrates proficiency*

Oral and Topical Nitrates frequency*

Narcotics *

Narcotics proficiency*

Narcotics frequency*

Potassium Supplements *

Potassium Supplements proficiency*

Potassium Supplements frequency*

Statin Medications *

Statin Medications proficiency*

Statin Medications frequency*

Pulmonary

Proficiency Rating

Frequency Rating

ASSESSMENT

Auscultation of Lung Sounds / Rate & Work of Breathing *

Auscultation of Lung Sounds / Rate & Work of Breathing proficiency*

Auscultation of Lung Sounds / Rate & Work of Breathing frequency*

Pulse Oximetry *

Pulse Oximetry proficiency*

Pulse Oximetry frequency*

ABGs *

ABGs proficiency*

ABGs frequency*

EQUIPMENT & PROCEDURES:

Administration of O2 via Nasal Cannula *

Administration of O2 via Nasal Cannula proficiency*

Administration of O2 via Nasal Cannula frequency*

Apnea Monitor *

Apnea Monitor proficiency*

Apnea Monitor frequency*

Chest Percussion *

Chest Percussion proficiency*

Chest Percussion frequency*

Establishing an Airway *

Establishing an Airway proficiency*

Establishing an Airway frequency*

Incentive Spirometry *

Incentive Spirometry proficiency*

Incentive Spirometry frequency*

Orotracheal and Nasotracheal Suctioning *

Orotracheal and Nasotracheal Suctioning proficiency*

Orotracheal and Nasotracheal Suctioning frequency*

Sputum Specimen Collection *

Sputum Specimen Collection proficiency*

Sputum Specimen Collection frequency*

Nebulizer *

Nebulizer proficiency*

Nebulizer frequency*

CPAP *

CPAP proficiency*

CPAP frequency*

BiPAP *

BiPAP proficiency*

BiPAP frequency*

Ventilator Management *

Ventilator Management proficiency*

Ventilator Management frequency*

CARE OF PATIENT WITH:

Asthma *

Asthma proficiency*

Asthma frequency*

Chronic Obstructive Pulmonary Disease (COPD) *

Chronic Obstructive Pulmonary Disease (COPD) proficiency*

Chronic Obstructive Pulmonary Disease (COPD) frequency*

Lung Cancer *

Lung Cancer proficiency*

Lung Cancer frequency*

Primary Pulmonary Hypertension *

Primary Pulmonary Hypertension proficiency*

Primary Pulmonary Hypertension frequency*

Pulmonary Fibrosis *

Pulmonary Fibrosis proficiency*

Pulmonary Fibrosis frequency*

Pulmonary Emboli *

Pulmonary Emboli proficiency*

Pulmonary Emboli frequency*

MEDICATION ADMINISTRATION:

Bronchodilators *

Bronchodilators proficiency*

Bronchodilators frequency*

Steroids *

Steroids proficiency*

Steroids frequency*

Expectorants *

Expectorants proficiency*

Expectorants frequency*

Inhalers *

Inhalers proficiency*

Inhalers frequency*

Neurological

Proficiency Rating

Frequency Rating

ASSESSMENT

Neurological Signs / Level of Consciousness (LOC) *

Neurological Signs / Level of Consciousness (LOC) proficiency*

Neurological Signs / Level of Consciousness (LOC) frequency*

Neuro - Motor / Sensory Functions *

Neuro - Motor / Sensory Functions proficiency*

Neuro - Motor / Sensory Functions frequency*

EQUIPMENT & PROCEDURES:

Seizure Precautions *

Seizure Precautions proficiency*

Seizure Precautions frequency*

Traction *

Traction proficiency*

Traction frequency*

CARE OF PATIENT WITH:

Alzheimer’s Disease *

Alzheimer’s Disease proficiency*

Alzheimer’s Disease frequency*

Dementia *

Dementia proficiency*

Dementia frequency*

Degenerative Neurological Disorders (ALS, MS, etc.) *

Degenerative Neurological Disorders (ALS, MS, etc.) proficiency*

Degenerative Neurological Disorders (ALS, MS, etc.) frequency*

Cerebral Tumors *

Cerebral Tumors proficiency*

Cerebral Tumors frequency*

Post - Cerebrovascular Accident *

Post - Cerebrovascular Accident proficiency*

Post - Cerebrovascular Accident frequency*

Guillain - Barre Syndrome *

Guillain - Barre Syndrome proficiency*

Guillain - Barre Syndrome frequency*

Hemiparesis *

Hemiparesis proficiency*

Hemiparesis frequency*

Meningitis *

Meningitis proficiency*

Meningitis frequency*

Parkinson’s Disease *

Parkinson’s Disease proficiency*

Parkinson’s Disease frequency*

Seizure Disorders *

Seizure Disorders proficiency*

Seizure Disorders frequency*

Paraplegia / Quadriplegia *

Paraplegia / Quadriplegia proficiency*

Paraplegia / Quadriplegia frequency*

Traumatic Brain Injury (TBI) *

Traumatic Brain Injury (TBI) proficiency*

Traumatic Brain Injury (TBI) frequency*

Transient Ischemic Attacks (TIAs) *

Transient Ischemic Attacks (TIAs) proficiency*

Transient Ischemic Attacks (TIAs) frequency*

MEDICATION ADMINISTRATION:

Alzheimer’s Medications *

Alzheimer’s Medications proficiency*

Alzheimer’s Medications frequency*

Anti - Parkinson’s Medications *

Anti - Parkinson’s Medications proficiency*

Anti - Parkinson’s Medications frequency*

Anti - Seizure Medications *

Anti - Seizure Medications proficiency*

Anti - Seizure Medications frequency*

Corticosteroids *

Corticosteroids proficiency*

Corticosteroids frequency*

Sedative / Hypnotics *

Sedative / Hypnotics proficiency*

Sedative / Hypnotics frequency*

Orthopedics

Proficiency Rating

Frequency Rating

ASSESSMENT

Incision Checks *

Incision Checks proficiency*

Incision Checks frequency*

Circulation / Skin Checks *

Circulation / Skin Checks proficiency*

Circulation / Skin Checks frequency*

Gait *

Gait proficiency*

Gait frequency*

Range of Motion *

Range of Motion proficiency*

Range of Motion frequency*

EQUIPMENT & PROCEDURES:

Range of Motion (Active & Passive) *

Range of Motion (Active & Passive) proficiency*

Range of Motion (Active & Passive) frequency*

Cast / Brace *

Cast / Brace proficiency*

Cast / Brace frequency*

Crutch / Walking *

Crutch / Walking proficiency*

Crutch / Walking frequency*

Assistive Devices *

Assistive Devices proficiency*

Assistive Devices frequency*

TENS Units *

TENS Units proficiency*

TENS Units frequency*

Wheelchairs / Lift Equipment *

Wheelchairs / Lift Equipment proficiency*

Wheelchairs / Lift Equipment frequency*

Total Hip / Knee / Joint Replacement *

Total Hip / Knee / Joint Replacement proficiency*

Total Hip / Knee / Joint Replacement frequency*

Total Hip / Knee / Joint Replacement *

Total Hip / Knee / Joint Replacement proficiency*

Total Hip / Knee / Joint Replacement frequency*

MEDICATION ADMINISTRATION:

Enoxaparin (Lovenox) *

Enoxaparin (Lovenox) proficiency*

Enoxaparin (Lovenox) frequency*

Gastrointestinal

Proficiency Rating

Frequency Rating

ASSESSMENT

Bowel Habits *

Bowel Habits proficiency*

Bowel Habits frequency*

Fluid Balance *

Fluid Balance proficiency*

Fluid Balance frequency*

INTERPRETATION OF LAB RESULTS:

Nutritional Status *

Nutritional Status proficiency*

Nutritional Status frequency*

EQUIPMENT & PROCEDURES:

Colostomy / Ileostomy Care *

Colostomy / Ileostomy Care proficiency*

Colostomy / Ileostomy Care frequency*

Long - Term Feeding Tube *

Long - Term Feeding Tube proficiency*

Long - Term Feeding Tube frequency*

Nasogastric (NG) Tube *

Nasogastric (NG) Tube proficiency*

Nasogastric (NG) Tube frequency*

PEG / Gastronomy Tube *

PEG / Gastronomy Tube proficiency*

PEG / Gastronomy Tube frequency*

Drainage Devices / Tubes *

Drainage Devices / Tubes proficiency*

Drainage Devices / Tubes frequency*

Tube Feeding *

Tube Feeding proficiency*

Tube Feeding frequency*

Feeding Pumps *

Feeding Pumps proficiency*

Feeding Pumps frequency*

CARE OF PATIENT WITH:

Bowel Obstruction *

Bowel Obstruction proficiency*

Bowel Obstruction frequency*

Fecal Incontinence *

Fecal Incontinence proficiency*

Fecal Incontinence frequency*

Gastrointestinal Bleeding (G.I. Bleed) *

Gastrointestinal Bleeding (G.I. Bleed) proficiency*

Gastrointestinal Bleeding (G.I. Bleed) frequency*

Post - Gastrointestinal Surgery *

Post - Gastrointestinal Surgery proficiency*

Post - Gastrointestinal Surgery frequency*

Hepatitis *

Hepatitis proficiency*

Hepatitis frequency*

Inflammatory Bowel Disease *

Inflammatory Bowel Disease proficiency*

Inflammatory Bowel Disease frequency*

Liver Failure / Transplant *

Liver Failure / Transplant proficiency*

Liver Failure / Transplant frequency*

Renal / Genitourinary

Proficiency Rating

Frequency Rating

ASSESSMENT

Arterio - Venous Fistula / Shunt *

Arterio - Venous Fistula / Shunt proficiency*

Arterio - Venous Fistula / Shunt frequency*

Fluid Balance *

Fluid Balance proficiency*

Fluid Balance frequency*

INTERPRETATION OF LAB RESULTS:

Blood Urea Nitrogen (BUN) *

Blood Urea Nitrogen (BUN) proficiency*

Blood Urea Nitrogen (BUN) frequency*

Serum Creatinine *

Serum Creatinine proficiency*

Serum Creatinine frequency*

Serum Electrolytes *

Serum Electrolytes proficiency*

Serum Electrolytes frequency*

EQUIPMENT & PROCEDURES:

3-Way Bladder Catheter *

3-Way Bladder Catheter proficiency*

3-Way Bladder Catheter frequency*

Foley Catheter Insertion / Maintenance *

Foley Catheter Insertion / Maintenance proficiency*

Foley Catheter Insertion / Maintenance frequency*

Straight Catheterization *

Straight Catheterization proficiency*

Straight Catheterization frequency*

Self - Catheterization *

Self - Catheterization proficiency*

Self - Catheterization frequency*

Ileostomy *

Ileostomy proficiency*

Ileostomy frequency*

Irrigations *

Irrigations proficiency*

Irrigations frequency*

Nephrostomy Tube *

Nephrostomy Tube proficiency*

Nephrostomy Tube frequency*

Suprapubic Catheter *

Suprapubic Catheter proficiency*

Suprapubic Catheter frequency*

CARE OF PATIENT WITH:

Hemodialysis (Receiving in an Out Pt. Clinic Setting) *

Hemodialysis (Receiving in an Out Pt. Clinic Setting) proficiency*

Hemodialysis (Receiving in an Out Pt. Clinic Setting) frequency*

Home Hemodialysis *

Home Hemodialysis proficiency*

Home Hemodialysis frequency*

Peritoneal Dialysis *

Peritoneal Dialysis proficiency*

Peritoneal Dialysis frequency*

Post - Bladder Surgery *

Post - Bladder Surgery proficiency*

Post - Bladder Surgery frequency*

Post - Prostate Surgery *

Post - Prostate Surgery proficiency*

Post - Prostate Surgery frequency*

Shunts and Fistulas *

Shunts and Fistulas proficiency*

Shunts and Fistulas frequency*

Urinary Incontinence *

Urinary Incontinence proficiency*

Urinary Incontinence frequency*

Endocrine / Metabolic

Proficiency Rating

Frequency Rating

ASSESSMENT

Diabetic Skin Assessment *

Diabetic Skin Assessment proficiency*

Diabetic Skin Assessment frequency*

Hyper - and Hypoglycemia *

Hyper - and Hypoglycemia proficiency*

Hyper - and Hypoglycemia frequency*

INTERPRETATION OF LAB RESULTS:

Hemoglobin A1C *

Hemoglobin A1C proficiency*

Hemoglobin A1C frequency*

Serum Glucose *

Serum Glucose proficiency*

Serum Glucose frequency*

EQUIPMENT & PROCEDURES:

Glucometers *

Glucometers proficiency*

Glucometers frequency*

Insulin Pumps *

Insulin Pumps proficiency*

Insulin Pumps frequency*

CARE OF PATIENT WITH:

Diabetes *

Diabetes proficiency*

Diabetes frequency*

Post - Transplantation Surgery *

Post - Transplantation Surgery proficiency*

Post - Transplantation Surgery frequency*

MEDICATION ADMINISTRATION:

Insulin *

Insulin proficiency*

Insulin frequency*

Oral Hypoglycemics *

Oral Hypoglycemics proficiency*

Oral Hypoglycemics frequency*

Wound / Skin Care Management

Proficiency Rating

Frequency Rating

ASSESSMENT

Wound Assessment Scale *

Wound Assessment Scale proficiency*

Wound Assessment Scale frequency*

Skin Assessment *

Skin Assessment proficiency*

Skin Assessment frequency*

Surgical Wound Healing *

Surgical Wound Healing proficiency*

Surgical Wound Healing frequency*

Skin Grafts *

Skin Grafts proficiency*

Skin Grafts frequency*

EQUIPMENT & PROCEDURES:

Burns *

Burns proficiency*

Burns frequency*

Care of Pressure Ulcers *

Care of Pressure Ulcers proficiency*

Care of Pressure Ulcers frequency*

Dry and Wet to Dry Dressing Changes *

Dry and Wet to Dry Dressing Changes proficiency*

Dry and Wet to Dry Dressing Changes frequency*

Positioning of Patients *

Positioning of Patients proficiency*

Positioning of Patients frequency*

Specialty Beds *

Specialty Beds proficiency*

Specialty Beds frequency*

Special Mattresses and Positioning Devices *

Special Mattresses and Positioning Devices proficiency*

Special Mattresses and Positioning Devices frequency*

Wound Care (Sterile) *

Wound Care (Sterile) proficiency*

Wound Care (Sterile) frequency*

Wound Cultures *

Wound Cultures proficiency*

Wound Cultures frequency*

Wound Irrigations *

Wound Irrigations proficiency*

Wound Irrigations frequency*

Wound Vac *

Wound Vac proficiency*

Wound Vac frequency*

CARE OF PATIENT WITH:

Burns *

Burns proficiency*

Burns frequency*

Pressure Ulcers *

Pressure Ulcers proficiency*

Pressure Ulcers frequency*

Surgical Wounds *

Surgical Wounds proficiency*

Surgical Wounds frequency*

Oncology

Proficiency Rating

Frequency Rating

ASSESSMENT

Immune Status *

Immune Status proficiency*

Immune Status frequency*

Symptoms Management *

Symptoms Management proficiency*

Symptoms Management frequency*

Signs / Symptoms of Infection *

Signs / Symptoms of Infection proficiency*

Signs / Symptoms of Infection frequency*

INTERPRETATION OF LAB RESULTS:

CBC with Differential *

CBC with Differential proficiency*

CBC with Differential frequency*

CMP *

CMP proficiency*

CMP frequency*

EQUIPMENT & PROCEDURES:

Reverse Isolation *

Reverse Isolation proficiency*

Reverse Isolation frequency*

CARE OF PATIENT WITH:

Radiation Therapy *

Radiation Therapy proficiency*

Radiation Therapy frequency*

Leukemia / Lymphoma *

Leukemia / Lymphoma proficiency*

Leukemia / Lymphoma frequency*

Post - Oncology Surgery *

Post - Oncology Surgery proficiency*

Post - Oncology Surgery frequency*

MEDICATION ADMINISTRATION:

Oral Chemotherapy *

Oral Chemotherapy proficiency*

Oral Chemotherapy frequency*

Intravenous Chemotherapy Administration *

Intravenous Chemotherapy Administration proficiency*

Intravenous Chemotherapy Administration frequency*

Intravenous Chemotherapy Monitoring *

Intravenous Chemotherapy Monitoring proficiency*

Intravenous Chemotherapy Monitoring frequency*

Bone Marrow Stimulating Agents *

Bone Marrow Stimulating Agents proficiency*

Bone Marrow Stimulating Agents frequency*

Infectious Disease

Proficiency Rating

Frequency Rating

ASSESSMENT

Signs / Symptoms of Infection *

Signs / Symptoms of Infection proficiency*

Signs / Symptoms of Infection frequency*

INTERPRETATION OF LAB RESULTS:

Blood Counts *

Blood Counts proficiency*

Blood Counts frequency*

Culture and Sensitivity *

Culture and Sensitivity proficiency*

Culture and Sensitivity frequency*

EQUIPMENT & PROCEDURES:

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

CARE OF PATIENT WITH:

C. Diff *

C. Diff proficiency*

C. Diff frequency*

HIV Infection *

HIV Infection proficiency*

HIV Infection frequency*

Tuberculosis *

Tuberculosis proficiency*

Tuberculosis frequency*

MRSA / VRE *

MRSA / VRE proficiency*

MRSA / VRE frequency*

MEDICATION ADMINISTRATION:

Antibiotics *

Antibiotics proficiency*

Antibiotics frequency*

Antivirals *

Antivirals proficiency*

Antivirals frequency*

Anti - HIV *

Anti - HIV proficiency*

Anti - HIV frequency*

Immunizations *

Immunizations proficiency*

Immunizations frequency*

Psychiatry

Proficiency Rating

Frequency Rating

ASSESSMENT

Monitoring Symptoms *

Monitoring Symptoms proficiency*

Monitoring Symptoms frequency*

Compliance with Medications *

Compliance with Medications proficiency*

Compliance with Medications frequency*

CARE OF PATIENT WITH:

Cognitive Disorders *

Cognitive Disorders proficiency*

Cognitive Disorders frequency*

Schizophrenia / Psychotic Disorders *

Schizophrenia / Psychotic Disorders proficiency*

Schizophrenia / Psychotic Disorders frequency*

Substance - Related Disorders *

Substance - Related Disorders proficiency*

Substance - Related Disorders frequency*

Mood Disorders (Anxiety / Depression, etc) *

Mood Disorders (Anxiety / Depression, etc) proficiency*

Mood Disorders (Anxiety / Depression, etc) frequency*

Womens Health / Maternal - Infant Care

Proficiency Rating

Frequency Rating

ASSESSMENT

Fetal Heart Tones *

Fetal Heart Tones proficiency*

Fetal Heart Tones frequency*

Contractions *

Contractions proficiency*

Contractions frequency*

CARE OF PATIENT WITH:

Breast Feeding *

Breast Feeding proficiency*

Breast Feeding frequency*

Pregnancy - Related Complications *

Pregnancy - Related Complications proficiency*

Pregnancy - Related Complications frequency*

Post - Mastectomy *

Post - Mastectomy proficiency*

Post - Mastectomy frequency*

Post - Partum Mother / Baby Visit *

Post - Partum Mother / Baby Visit proficiency*

Post - Partum Mother / Baby Visit frequency*

Newborn Care *

Newborn Care proficiency*

Newborn Care frequency*

Bulb Suctioning *

Bulb Suctioning proficiency*

Bulb Suctioning frequency*

Cord and Circumcision Care *

Cord and Circumcision Care proficiency*

Cord and Circumcision Care frequency*

Phototherapy *

Phototherapy proficiency*

Phototherapy frequency*

Pediatrics

Proficiency Rating

Frequency Rating

ASSESSMENT

Growth *

Growth proficiency*

Growth frequency*

Development Stages *

Development Stages proficiency*

Development Stages frequency*

Nutrition *

Nutrition proficiency*

Nutrition frequency*

Family / Caregiver Interaction *

Family / Caregiver Interaction proficiency*

Family / Caregiver Interaction frequency*

EQUIPMENT & PROCEDURES:

Calculations of Pediatric Dosages *

Calculations of Pediatric Dosages proficiency*

Calculations of Pediatric Dosages frequency*

Croup Tent *

Croup Tent proficiency*

Croup Tent frequency*

Ventilator *

Ventilator proficiency*

Ventilator frequency*

Trach *

Trach proficiency*

Trach frequency*

Pediatric Ambu *

Pediatric Ambu proficiency*

Pediatric Ambu frequency*

Near Drowning *

Near Drowning proficiency*

Near Drowning frequency*

Pre - and Post - Cardiac Surgery *

Pre - and Post - Cardiac Surgery proficiency*

Pre - and Post - Cardiac Surgery frequency*

CARE OF PATIENT WITH:

Broncho Pulmonary Dysplasia *

Broncho Pulmonary Dysplasia proficiency*

Broncho Pulmonary Dysplasia frequency*

Cystic Fibrosis *

Cystic Fibrosis proficiency*

Cystic Fibrosis frequency*

Respiratory Distress Syndrome (RDS) *

Respiratory Distress Syndrome (RDS) proficiency*

Respiratory Distress Syndrome (RDS) frequency*

Reyes Syndrome *

Reyes Syndrome proficiency*

Reyes Syndrome frequency*

Pre - and Post - Spinal Surgery *

Pre - and Post - Spinal Surgery proficiency*

Pre - and Post - Spinal Surgery frequency*

Sickle Cell Disease *

Sickle Cell Disease proficiency*

Sickle Cell Disease frequency*

Spina Bifida *

Spina Bifida proficiency*

Spina Bifida frequency*

Pain Management

Proficiency Rating

Frequency Rating

ASSESSMENT

Pain Scale *

Pain Scale proficiency*

Pain Scale frequency*

Response to Pain Management Interventions *

Response to Pain Management Interventions proficiency*

Response to Pain Management Interventions frequency*

EQUIPMENT & PROCEDURES:

Pharmacologic Pain Relief *

Pharmacologic Pain Relief proficiency*

Pharmacologic Pain Relief frequency*

Non - pharmacologic Pain Relief Measures *

Non - pharmacologic Pain Relief Measures proficiency*

Non - pharmacologic Pain Relief Measures frequency*

PCA Pump *

PCA Pump proficiency*

PCA Pump frequency*

CARE OF PATIENT WITH:

Epidural Catheter / Site Monitoring / Pump *

Epidural Catheter / Site Monitoring / Pump proficiency*

Epidural Catheter / Site Monitoring / Pump frequency*

Patient Controlled Analgesia *

Patient Controlled Analgesia proficiency*

Patient Controlled Analgesia frequency*

Palliative and End - of - Life Care

Proficiency Rating

Frequency Rating

Family Support and Teaching *

Family Support and Teaching proficiency*

Family Support and Teaching frequency*

Medication Protocols *

Medication Protocols proficiency*

Medication Protocols frequency*

Symptom Management *

Symptom Management proficiency*

Symptom Management frequency*

After Death Protocol and Management *

After Death Protocol and Management proficiency*

After Death Protocol and Management frequency*

Patient and Family Teaching

Proficiency Rating

Frequency Rating

Diabetic *

Diabetic proficiency*

Diabetic frequency*

Pre - and Post - Procedure *

Pre - and Post - Procedure proficiency*

Pre - and Post - Procedure frequency*

Post - partum / Infant Care *

Post - partum / Infant Care proficiency*

Post - partum / Infant Care frequency*

Medications *

Medications proficiency*

Medications frequency*

Monitoring *

Monitoring proficiency*

Monitoring frequency*

Nutrition *

Nutrition proficiency*

Nutrition frequency*

Safety *

Safety proficiency*

Safety frequency*

Self - care *

Self - care proficiency*

Self - care frequency*

Equipment *

Equipment proficiency*

Equipment frequency*

Resources *

Resources proficiency*

Resources frequency*

Miscellaneous

Proficiency Rating

Frequency Rating

APS / CPS Reporting *

APS / CPS Reporting proficiency*

APS / CPS Reporting frequency*

Fall Assessment and Prevention *

Fall Assessment and Prevention proficiency*

Fall Assessment and Prevention frequency*

National Patient Safety Goals *

National Patient Safety Goals proficiency*

National Patient Safety Goals frequency*

Safety Assessment *

Safety Assessment proficiency*

Safety Assessment frequency*

Recognizing Failure to Thrive Across the Lifespan *

Recognizing Failure to Thrive Across the Lifespan proficiency*

Recognizing Failure to Thrive Across the Lifespan frequency*

Advanced Directives *

Advanced Directives proficiency*

Advanced Directives frequency*

Wheelchairs / Lift Equipment *

Wheelchairs / Lift Equipment proficiency*

Wheelchairs / Lift Equipment frequency*

Case Management

Proficiency Rating

Frequency Rating

Experience as a Case Manager *

Experience as a Case Manager proficiency*

Experience as a Case Manager frequency*

Case Load *

Case Load proficiency*

Case Load frequency*

Supervision of Home Health Aides *

Supervision of Home Health Aides proficiency*

Supervision of Home Health Aides frequency*

Experience with:

Proficiency Rating

Frequency Rating

Long - term / Short - term Disability *

Long - term / Short - term Disability proficiency*

Long - term / Short - term Disability frequency*

Management of Complaints *

Management of Complaints proficiency*

Management of Complaints frequency*

Medicare / Medicaid *

Medicare / Medicaid proficiency*

Medicare / Medicaid frequency*

Pre - certifications *

Pre - certifications proficiency*

Pre - certifications frequency*

Private Insurance *

Private Insurance proficiency*

Private Insurance frequency*

Telephone Assessments *

Telephone Assessments proficiency*

Telephone Assessments frequency*

Utilization Review *

Utilization Review proficiency*

Utilization Review frequency*

Workman’s Compensation *

Workman’s Compensation proficiency*

Workman’s Compensation frequency*

Documentation

Proficiency Rating

Frequency Rating

Diagnosis Coding (ICD Coding) *

Diagnosis Coding (ICD Coding) proficiency*

Diagnosis Coding (ICD Coding) frequency*

Document Plan of Care (Form 485) *

Document Plan of Care (Form 485) proficiency*

Document Plan of Care (Form 485) frequency*

OASIS Documentation *

OASIS Documentation proficiency*

OASIS Documentation 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

Signature*

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Date*

Skills/Competences

Proficiency

Frequency

HOME HEALTH LPN

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