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*
General Skills
Proficiency Rating
Frequency Rating
Standard Precautions *
Standard Precautions proficiency* Standard Precautions frequency* Isolation Precautions *
Isolation Precautions proficiency* Isolation Precautions frequency* Discontinue PIV *
Discontinue PIV proficiency* Discontinue PIV frequency* Initiate Peripheral IV *
Initiate Peripheral IV proficiency* Initiate Peripheral IV frequency* Lift / Transfer Devices *
Lift / Transfer Devices proficiency* Lift / Transfer Devices 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* Patient / Family Education *
Patient / Family Education proficiency* Patient / Family Education frequency* Electronic Documentation *
Electronic Documentation proficiency* Electronic Documentation frequency* Patient Head to Toe Assessment *
Patient Head to Toe Assessment proficiency* Patient Head to Toe Assessment frequency* Knowledge of Normal Serum Lab Values *
Knowledge of Normal Serum Lab Values proficiency* Knowledge of Normal Serum Lab Values frequency* Obtaining Cultures (Blood, Sputum, Swab) *
Obtaining Cultures (Blood, Sputum, Swab) proficiency* Obtaining Cultures (Blood, Sputum, Swab) frequency* Calculate mcg / min and mcg / kg / min *
Calculate mcg / min and mcg / kg / min proficiency* Calculate mcg / min and mcg / kg / min frequency* Titrating Medications *
Titrating Medications proficiency* Titrating Medications frequency*
Psychological
Proficiency Rating
Frequency Rating
Overdose / Withdrawal *
Overdose / Withdrawal proficiency* Overdose / Withdrawal frequency* Suicidal Precautions *
Suicidal Precautions proficiency* Suicidal Precautions frequency* Manic Disorder / Behavior *
Manic Disorder / Behavior proficiency* Manic Disorder / Behavior frequency* De-escalation techniques *
De-escalation techniques proficiency* De-escalation techniques frequency* Depression *
Depression proficiency* Depression frequency* KNOWLEDGE AND USE OF:
Anti-depressants *
Anti-depressants proficiency* Anti-depressants frequency* Anti-anxiety Medications *
Anti-anxiety Medications proficiency* Anti-anxiety Medications frequency* Psych Medications *
Psych Medications proficiency* Psych Medications frequency*
Medications
Proficiency Rating
Frequency Rating
Anticoagulants *
Anticoagulants proficiency* Anticoagulants frequency* Narcotics *
Narcotics proficiency* Narcotics frequency* PCA for Pain Control *
PCA for Pain Control proficiency* PCA for Pain Control frequency* Epidural for Pain Control *
Epidural for Pain Control proficiency* Epidural for Pain Control frequency* Non-narcotic Analgesics *
Non-narcotic Analgesics proficiency* Non-narcotic Analgesics frequency* Topical Medications *
Topical Medications proficiency* Topical Medications frequency* IM Medications *
IM Medications proficiency* IM Medications frequency* SQ Medications *
SQ Medications proficiency* SQ Medications frequency* Oral Medications *
Oral Medications proficiency* Oral Medications frequency* IV Push Medications *
IV Push Medications proficiency* IV Push Medications frequency* IV Drip Medications *
IV Drip Medications proficiency* IV Drip Medications frequency* Antibiotics *
Antibiotics proficiency* Antibiotics frequency* Chemotherapy *
Chemotherapy proficiency* Chemotherapy frequency*
Neuro General Skills
Proficiency Rating
Frequency Rating
Assessing Levels of Consciousness *
Assessing Levels of Consciousness proficiency* Assessing Levels of Consciousness frequency* Pupil Checks *
Pupil Checks proficiency* Pupil Checks frequency* Seizure Precautions *
Seizure Precautions proficiency* Seizure Precautions frequency* Aneurysm Precautions *
Aneurysm Precautions proficiency* Aneurysm Precautions frequency* Assisting with Lumbar Puncture *
Assisting with Lumbar Puncture proficiency* Assisting with Lumbar Puncture frequency* Use of Hyper / Hypothermia Blanket *
Use of Hyper / Hypothermia Blanket proficiency* Use of Hyper / Hypothermia Blanket frequency*
Neuro - Care of Patients with:
Proficiency Rating
Frequency Rating
Stroke *
Stroke proficiency* Stroke frequency* Spinal Cord Injury - Acute *
Spinal Cord Injury - Acute proficiency* Spinal Cord Injury - Acute frequency* Spinal Cord Injury – Long Term *
Spinal Cord Injury – Long Term proficiency* Spinal Cord Injury – Long Term frequency* Neuromuscular Disease *
Neuromuscular Disease proficiency* Neuromuscular Disease frequency* Alzheimer’s Disease *
Alzheimer’s Disease proficiency* Alzheimer’s Disease frequency* KNOWLEDGE AND USE OF:
Anticonvulsants *
Anticonvulsants proficiency* Anticonvulsants frequency* IV Drip Steroids *
IV Drip Steroids proficiency* IV Drip Steroids frequency*
Cardiac General Skills
Proficiency Rating
Frequency Rating
Cardiac Monitors *
Cardiac Monitors proficiency* Cardiac Monitors frequency* Auscultation of Cardiac Sounds *
Auscultation of Cardiac Sounds proficiency* Auscultation of Cardiac Sounds frequency* EKG - 12 Lead *
EKG - 12 Lead proficiency* EKG - 12 Lead frequency* Recognizing Basic & Life-Threatening Dysrhythmias *
Recognizing Basic & Life-Threatening Dysrhythmias proficiency* Recognizing Basic & Life-Threatening Dysrhythmias frequency* Cardioversion / Defibrillation *
Cardioversion / Defibrillation proficiency* Cardioversion / Defibrillation frequency* Pulse Checks *
Pulse Checks proficiency* Pulse Checks frequency* Interpretation of Cardiac Enzymes *
Interpretation of Cardiac Enzymes proficiency* Interpretation of Cardiac Enzymes frequency* Use of Doppler *
Use of Doppler proficiency* Use of Doppler frequency* Use of Automatic BP Cuff (ie Dinamap) *
Use of Automatic BP Cuff (ie Dinamap) proficiency* Use of Automatic BP Cuff (ie Dinamap) frequency*
Cardiac - Care of Patient with:
Proficiency Rating
Frequency Rating
Angina *
Angina proficiency* Angina frequency* CHF *
CHF proficiency* CHF frequency* Chest Pain *
Chest Pain proficiency* Chest Pain frequency* Post MI *
Post MI proficiency* Post MI frequency* KNOWLEDGE AND USE OF:
Nitrates (Oral, Topical) *
Nitrates (Oral, Topical) proficiency* Nitrates (Oral, Topical) frequency* Antiarrhythmics (Oral) *
Antiarrhythmics (Oral) proficiency* Antiarrhythmics (Oral) frequency* Antihypertensives (Oral) *
Antihypertensives (Oral) proficiency* Antihypertensives (Oral) frequency* Heparin Drip *
Heparin Drip proficiency* Heparin Drip frequency*
Respiratory General Skills
Proficiency Rating
Frequency Rating
O2 Cannulas / Masks *
O2 Cannulas / Masks proficiency* O2 Cannulas / Masks frequency* Nebulizer Set-up / Use *
Nebulizer Set-up / Use proficiency* Nebulizer Set-up / Use frequency* Incentive Spirometry *
Incentive Spirometry proficiency* Incentive Spirometry frequency* Chest PT *
Chest PT proficiency* Chest PT frequency* Pulse Oximetry *
Pulse Oximetry proficiency* Pulse Oximetry frequency* SUCTIONING:
Oral *
Oral proficiency* Oral frequency* Tracheostomy Tube *
Tracheostomy Tube proficiency* Tracheostomy Tube frequency*
Respiratory - Care of Patient with:
Proficiency Rating
Frequency Rating
SOB *
SOB proficiency* SOB frequency* Pulmonary Embolism *
Pulmonary Embolism proficiency* Pulmonary Embolism frequency* Tracheostomy Tube *
Tracheostomy Tube proficiency* Tracheostomy Tube frequency* COPD *
COPD proficiency* COPD frequency* Asthma Exacerbation *
Asthma Exacerbation proficiency* Asthma Exacerbation frequency* Pneumonia *
Pneumonia proficiency* Pneumonia frequency* Pre / Post Thoracic Surgery *
Pre / Post Thoracic Surgery proficiency* Pre / Post Thoracic Surgery frequency* Chest Tubes *
Chest Tubes proficiency* Chest Tubes frequency* Tuberculosis *
Tuberculosis proficiency* Tuberculosis frequency* KNOWLEDGE AND USE OF:
O2 Therapy *
O2 Therapy proficiency* O2 Therapy frequency* Bronchodilators *
Bronchodilators proficiency* Bronchodilators frequency* Oral Steroids *
Oral Steroids proficiency* Oral Steroids frequency* IV Steroids *
IV Steroids proficiency* IV Steroids frequency* Inhaler *
Inhaler proficiency* Inhaler frequency*
Gastrointestinal General Skills
Proficiency Rating
Frequency Rating
Insertion, Care & Maintenance of Nasogastric Tubes (ie Salem Pump, Levine) *
Insertion, Care & Maintenance of Nasogastric Tubes (ie Salem Pump, Levine) proficiency* Insertion, Care & Maintenance of Nasogastric Tubes (ie Salem Pump, Levine) frequency* Nasointestinal Tubes (ie Cantor, Miller-Abbot) *
Nasointestinal Tubes (ie Cantor, Miller-Abbot) proficiency* Nasointestinal Tubes (ie Cantor, Miller-Abbot) frequency* Jejunostomy, Gastrostomy, Cecostomy Tubes *
Jejunostomy, Gastrostomy, Cecostomy Tubes proficiency* Jejunostomy, Gastrostomy, Cecostomy Tubes frequency* TUBE FEEDINGS VIA FLEXIBLE TUBES:
by Gravity Infusion *
by Gravity Infusion proficiency* by Gravity Infusion frequency* by Feeding Pump *
by Feeding Pump proficiency* by Feeding Pump frequency* Collection of Stool Specimens *
Collection of Stool Specimens proficiency* Collection of Stool Specimens frequency* Bowel Preparation & Cleansing Procedures *
Bowel Preparation & Cleansing Procedures proficiency* Bowel Preparation & Cleansing Procedures frequency*
Gastrointestinal - Care of Patients with:
Proficiency Rating
Frequency Rating
Stoma *
Stoma proficiency* Stoma frequency* Bowel Obstruction *
Bowel Obstruction proficiency* Bowel Obstruction frequency* Pancreatitis *
Pancreatitis proficiency* Pancreatitis frequency* Post Abdominal Surgery *
Post Abdominal Surgery proficiency* Post Abdominal Surgery frequency* Ileostomy *
Ileostomy proficiency* Ileostomy frequency* Colostomy *
Colostomy proficiency* Colostomy frequency* Inflammatory Bowel Disease *
Inflammatory Bowel Disease proficiency* Inflammatory Bowel Disease frequency* Obstruction *
Obstruction proficiency* Obstruction frequency* Hepatitis *
Hepatitis proficiency* Hepatitis frequency* KNOWLEDGE AND USE OF:
Total Parenteral Nutrition (TPN) *
Total Parenteral Nutrition (TPN) proficiency* Total Parenteral Nutrition (TPN) frequency* Peripheral Parenteral Nutrition (PPN) *
Peripheral Parenteral Nutrition (PPN) proficiency* Peripheral Parenteral Nutrition (PPN) frequency* Antiemetics *
Antiemetics proficiency* Antiemetics frequency* Proton Pump Inhibitors *
Proton Pump Inhibitors proficiency* Proton Pump Inhibitors frequency*
Renal / GU Problems General Skills
Proficiency Rating
Frequency Rating
Insertion of Catheter Straight *
Insertion of Catheter Straight proficiency* Insertion of Catheter Straight frequency* Insertion of Catheter Foley *
Insertion of Catheter Foley proficiency* Insertion of Catheter Foley frequency* Bladder Irrigation Continuous *
Bladder Irrigation Continuous proficiency* Bladder Irrigation Continuous frequency* Bladder Irrigation Intermittent *
Bladder Irrigation Intermittent proficiency* Bladder Irrigation Intermittent frequency* Peritoneal Dialysis *
Peritoneal Dialysis proficiency* Peritoneal Dialysis frequency* Automatic Cycler Machine *
Automatic Cycler Machine proficiency* Automatic Cycler Machine frequency* Collection of Urine Specimens *
Collection of Urine Specimens proficiency* Collection of Urine Specimens frequency* Hemodialysis *
Hemodialysis proficiency* Hemodialysis frequency* A-V Fistula / Shunt Care *
A-V Fistula / Shunt Care proficiency* A-V Fistula / Shunt Care frequency* Pre - & Post - Dialysis Care *
Pre - & Post - Dialysis Care proficiency* Pre - & Post - Dialysis Care frequency* Suprapubic Catheter *
Suprapubic Catheter proficiency* Suprapubic Catheter frequency* Nephrostomy Tube *
Nephrostomy Tube proficiency* Nephrostomy Tube frequency*
Renal / GU - Care Of Patient With:
Proficiency Rating
Frequency Rating
Urinary Tract Infection *
Urinary Tract Infection proficiency* Urinary Tract Infection frequency* Pyelonephritis *
Pyelonephritis proficiency* Pyelonephritis frequency* Renal Calculi *
Renal Calculi proficiency* Renal Calculi frequency* Urinary Retention / Incontinence *
Urinary Retention / Incontinence proficiency* Urinary Retention / Incontinence frequency*
Endocrine General Skills
Proficiency Rating
Frequency Rating
Performing Fingersticks *
Performing Fingersticks proficiency* Performing Fingersticks frequency* Use of Blood Glucose Meter Device *
Use of Blood Glucose Meter Device proficiency* Use of Blood Glucose Meter Device frequency* Use of Visual Blood Glucose Strips *
Use of Visual Blood Glucose Strips proficiency* Use of Visual Blood Glucose Strips frequency* ENDOCRINE - CARE OF PATIENT WITH:
Hyper / Hypoglycemia *
Hyper / Hypoglycemia proficiency* Hyper / Hypoglycemia frequency* DKA *
DKA proficiency* DKA frequency* Thyroid Disorders *
Thyroid Disorders proficiency* Thyroid Disorders frequency* KNOWLEDGE AND USE OF INSULIN:
Single Type *
Single Type proficiency* Single Type frequency* Dextrose *
Dextrose proficiency* Dextrose frequency* Mixed Insulins *
Mixed Insulins proficiency* Mixed Insulins frequency* Insulin Infusion *
Insulin Infusion proficiency* Insulin Infusion frequency*
Orthopedic General Skills
Proficiency Rating
Frequency Rating
Cast Care *
Cast Care proficiency* Cast Care frequency* C.M.S. Checks *
C.M.S. Checks proficiency* C.M.S. Checks frequency* Traction – Skin *
Traction – Skin proficiency* Traction – Skin frequency* Traction – Skeletal *
Traction – Skeletal proficiency* Traction – Skeletal frequency* Range of Motion *
Range of Motion proficiency* Range of Motion frequency* Use of Assistive Devices *
Use of Assistive Devices proficiency* Use of Assistive Devices frequency* Applications of Splints Extremities *
Applications of Splints Extremities proficiency* Applications of Splints Extremities frequency* Continuous Passive Motion Machine (CPM) *
Continuous Passive Motion Machine (CPM) proficiency* Continuous Passive Motion Machine (CPM) frequency*
Orthopedic - Care Of Patients With:
Proficiency Rating
Frequency Rating
Total Joint Replacement *
Total Joint Replacement proficiency* Total Joint Replacement frequency* Rheumatic / Arthritic Disease *
Rheumatic / Arthritic Disease proficiency* Rheumatic / Arthritic Disease frequency* Amputation *
Amputation proficiency* Amputation frequency*
Wound / Skin Care
Proficiency Rating
Frequency Rating
Dressing Changes *
Dressing Changes proficiency* Dressing Changes frequency* Air Fluidized, Low Airloss Beds *
Air Fluidized, Low Airloss Beds proficiency* Air Fluidized, Low Airloss Beds frequency* Pressure Relief Mattress / Seat Cushion *
Pressure Relief Mattress / Seat Cushion proficiency* Pressure Relief Mattress / Seat Cushion frequency* Pressure Sores *
Pressure Sores proficiency* Pressure Sores frequency* Leg Ulcers *
Leg Ulcers proficiency* Leg Ulcers frequency* Burns *
Burns proficiency* Burns frequency*
Wound Vacs
Proficiency Rating
Frequency Rating
Hemovacs *
Hemovacs proficiency* Hemovacs frequency* Jackson-Pratt Tubes *
Jackson-Pratt Tubes proficiency* Jackson-Pratt Tubes frequency* Penrose Drains *
Penrose Drains proficiency* Penrose Drains frequency* T-Tubes *
T-Tubes proficiency* T-Tubes frequency* Surgical Wound Irrigations & Dressings *
Surgical Wound Irrigations & Dressings proficiency* Surgical Wound Irrigations & Dressings frequency*
Vascular
Proficiency Rating
Frequency Rating
Discontinue PICC *
Discontinue PICC proficiency* Discontinue PICC frequency* Care of Patient with DVT *
Care of Patient with DVT proficiency* Care of Patient with DVT frequency* Draw Blood from Arterial Line *
Draw Blood from Arterial Line proficiency* Draw Blood from Arterial Line frequency* Draw Blood from Central Line *
Draw Blood from Central Line proficiency* Draw Blood from Central Line frequency* Peripheral IV Insertion, Care & Maintenance *
Peripheral IV Insertion, Care & Maintenance proficiency* Peripheral IV Insertion, Care & Maintenance frequency* Discontinue Peripheral IV *
Discontinue Peripheral IV proficiency* Discontinue Peripheral IV frequency* IV Infusion Pumps *
IV Infusion Pumps proficiency* IV Infusion Pumps frequency* CVP Lines – Measurement of CVP *
CVP Lines – Measurement of CVP proficiency* CVP Lines – Measurement of CVP frequency* Central Line Care & Maintenance (including dressing changes) *
Central Line Care & Maintenance (including dressing changes) proficiency* Central Line Care & Maintenance (including dressing changes) frequency* Blood / Blood Product Administration *
Blood / Blood Product Administration proficiency* Blood / Blood Product Administration frequency* Multi-Lumen Central Catheters *
Multi-Lumen Central Catheters proficiency* Multi-Lumen Central Catheters frequency* Port-A-Caths (Infusa-Ports) *
Port-A-Caths (Infusa-Ports) proficiency* Port-A-Caths (Infusa-Ports) frequency* Continuous Subcutaneous Infusion Pumps *
Continuous Subcutaneous Infusion Pumps proficiency* Continuous Subcutaneous Infusion Pumps 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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