Nurse Manager

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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*

Crash Carts *

Crash Carts proficiency*

Crash Carts frequency*

Defibrillators *

Defibrillators proficiency*

Defibrillators frequency*

Advanced Directives *

Advanced Directives proficiency*

Advanced Directives frequency*

Admission *

Admission proficiency*

Admission frequency*

Collect Appropriate Data *

Collect Appropriate Data proficiency*

Collect Appropriate Data frequency*

Organ / Tissue Donation *

Organ / Tissue Donation proficiency*

Organ / Tissue Donation 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:

Setting

Proficiency Rating

Frequency Rating

Hospital *

Hospital proficiency*

Hospital frequency*

Outpatient Clinic *

Outpatient Clinic proficiency*

Outpatient Clinic frequency*

Post - Acute Care *

Post - Acute Care proficiency*

Post - Acute Care frequency*

Nursing Management

Proficiency Rating

Frequency Rating

Staffing and Scheduling Nursing Unit *

Staffing and Scheduling Nursing Unit proficiency*

Staffing and Scheduling Nursing Unit frequency*

Quality Improvement *

Quality Improvement proficiency*

Quality Improvement frequency*

Employee Health / Injuries *

Employee Health / Injuries proficiency*

Employee Health / Injuries frequency*

Experience with Regulatory Agencies *

Experience with Regulatory Agencies proficiency*

Experience with Regulatory Agencies frequency*

On - Call Staff *

On - Call Staff proficiency*

On - Call Staff frequency*

Bed Control *

Bed Control proficiency*

Bed Control frequency*

Internal / External Disasters *

Internal / External Disasters proficiency*

Internal / External Disasters frequency*

Violent / Abusive Patient *

Violent / Abusive Patient proficiency*

Violent / Abusive Patient frequency*

Patient Elopement *

Patient Elopement proficiency*

Patient Elopement frequency*

Capacity Issues *

Capacity Issues proficiency*

Capacity Issues frequency*

Staffing by Acuity *

Staffing by Acuity proficiency*

Staffing by Acuity frequency*

Recruitment and Retention Strategies *

Recruitment and Retention Strategies proficiency*

Recruitment and Retention Strategies frequency*

Hiring New Staff *

Hiring New Staff proficiency*

Hiring New Staff frequency*

On - Boarding of New Staff *

On - Boarding of New Staff proficiency*

On - Boarding of New Staff frequency*

Annual Evaluations *

Annual Evaluations proficiency*

Annual Evaluations frequency*

Employee Coaching / Counseling *

Employee Coaching / Counseling proficiency*

Employee Coaching / Counseling frequency*

Infection Control *

Infection Control proficiency*

Infection Control frequency*

Analyzing Unit Financials *

Analyzing Unit Financials proficiency*

Analyzing Unit Financials frequency*

Budgeting Process and Standards *

Budgeting Process and Standards proficiency*

Budgeting Process and Standards frequency*

Supply Inventory Management *

Supply Inventory Management proficiency*

Supply Inventory Management frequency*

Coordinate Patient Care Plans *

Coordinate Patient Care Plans proficiency*

Coordinate Patient Care Plans frequency*

Providing Medical and Mentoring to Staff *

Providing Medical and Mentoring to Staff proficiency*

Providing Medical and Mentoring to Staff frequency*

Addressing Patient Issues / Complaints Promptly *

Addressing Patient Issues / Complaints Promptly proficiency*

Addressing Patient Issues / Complaints Promptly frequency*

Cardiovascular

Proficiency Rating

Frequency Rating

Acute MI *

Acute MI proficiency*

Acute MI frequency*

Angina *

Angina proficiency*

Angina frequency*

Congestive Heart Failure *

Congestive Heart Failure proficiency*

Congestive Heart Failure frequency*

Pacemaker *

Pacemaker proficiency*

Pacemaker frequency*

Pulmonary

Proficiency Rating

Frequency Rating

Acute Pneumonia *

Acute Pneumonia proficiency*

Acute Pneumonia frequency*

Asthma *

Asthma proficiency*

Asthma frequency*

COPD *

COPD proficiency*

COPD frequency*

Pulmonary Edema *

Pulmonary Edema proficiency*

Pulmonary Edema frequency*

Pulmonary Embolism *

Pulmonary Embolism proficiency*

Pulmonary Embolism frequency*

Tracheostomy *

Tracheostomy proficiency*

Tracheostomy frequency*

Neurological

Proficiency Rating

Frequency Rating

Acute Head Injury *

Acute Head Injury proficiency*

Acute Head Injury frequency*

Dementia *

Dementia proficiency*

Dementia frequency*

Stroke *

Stroke proficiency*

Stroke frequency*

Seizure Disorder *

Seizure Disorder proficiency*

Seizure Disorder frequency*

Gastrointestinal

Proficiency Rating

Frequency Rating

Abdominal Wounds and Surgeries *

Abdominal Wounds and Surgeries proficiency*

Abdominal Wounds and Surgeries frequency*

Bowel Obstruction Colostomy *

Bowel Obstruction Colostomy proficiency*

Bowel Obstruction Colostomy frequency*

GI Bleeding *

GI Bleeding proficiency*

GI Bleeding frequency*

Pancreatitis *

Pancreatitis proficiency*

Pancreatitis frequency*

Paralytic Ileus *

Paralytic Ileus proficiency*

Paralytic Ileus frequency*

Renal / Genitourinary

Proficiency Rating

Frequency Rating

Acute Renal Failure *

Acute Renal Failure proficiency*

Acute Renal Failure frequency*

End Stage Renal Disease *

End Stage Renal Disease proficiency*

End Stage Renal Disease frequency*

Hemodialysis *

Hemodialysis proficiency*

Hemodialysis frequency*

Peritoneal Dialysis *

Peritoneal Dialysis proficiency*

Peritoneal Dialysis frequency*

Suprapubic Cath *

Suprapubic Cath proficiency*

Suprapubic Cath frequency*

Endocrine / Metabolic / Toxicology

Proficiency Rating

Frequency Rating

Diabetes *

Diabetes proficiency*

Diabetes frequency*

Diabetic Ketoacidosis *

Diabetic Ketoacidosis proficiency*

Diabetic Ketoacidosis frequency*

Drug Overdose *

Drug Overdose proficiency*

Drug Overdose frequency*

Illicit Drug Overdose *

Illicit Drug Overdose proficiency*

Illicit Drug Overdose frequency*

Muscoloskeletal

Proficiency Rating

Frequency Rating

Traction *

Traction proficiency*

Traction frequency*

Amputation *

Amputation proficiency*

Amputation frequency*

External Fixation *

External Fixation proficiency*

External Fixation frequency*

Paraplegia *

Paraplegia proficiency*

Paraplegia frequency*

Rheumatoid Arthritis *

Rheumatoid Arthritis proficiency*

Rheumatoid Arthritis frequency*

Joint Replacement *

Joint Replacement proficiency*

Joint Replacement frequency*

Immunology / Hematology / Oncology

Proficiency Rating

Frequency Rating

HIV / AIDS *

HIV / AIDS proficiency*

HIV / AIDS frequency*

Sickle Cell Anemia *

Sickle Cell Anemia proficiency*

Sickle Cell Anemia frequency*

Acute Leukemia *

Acute Leukemia proficiency*

Acute Leukemia frequency*

Treatment Side Effects *

Treatment Side Effects proficiency*

Treatment Side Effects frequency*

Chemo / Radiation *

Chemo / Radiation proficiency*

Chemo / Radiation frequency*

Sepsis *

Sepsis proficiency*

Sepsis frequency*

Wounds / Integument

Proficiency Rating

Frequency Rating

Pressure Injury / Ulcers *

Pressure Injury / Ulcers proficiency*

Pressure Injury / Ulcers frequency*

Skin Breakdown *

Skin Breakdown proficiency*

Skin Breakdown frequency*

Medication / Therapeutic Interventions

Proficiency Rating

Frequency Rating

Administer PO Medications *

Administer PO Medications proficiency*

Administer PO Medications frequency*

Administer IM / SQ Medications *

Administer IM / SQ Medications proficiency*

Administer IM / SQ Medications frequency*

Administer IV Medications *

Administer IV Medications proficiency*

Administer IV Medications frequency*

Insert PIV *

Insert PIV proficiency*

Insert PIV frequency*

Assess IV Insertion *

Assess IV Insertion proficiency*

Assess IV Insertion frequency*

Multi - Lumen Central Venous Catheters *

Multi - Lumen Central Venous Catheters proficiency*

Multi - Lumen Central Venous Catheters frequency*

Infusion / PCA Pumps *

Infusion / PCA Pumps proficiency*

Infusion / PCA Pumps frequency*

Administer Blood / Blood Products *

Administer Blood / Blood Products proficiency*

Administer Blood / Blood Products frequency*

NGT Insertion *

NGT Insertion proficiency*

NGT Insertion frequency*

Dobhoff Insertion *

Dobhoff Insertion proficiency*

Dobhoff Insertion frequency*

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 Mask frequency*

Portable Oxygen *

Portable Oxygen proficiency*

Portable Oxygen frequency*

Tracheostomy Tube *

Tracheostomy Tube proficiency*

Tracheostomy Tube frequency*

Ventilators *

Ventilators proficiency*

Ventilators frequency*

Epidural Anesthesia / Analgesia *

Epidural Anesthesia / Analgesia proficiency*

Epidural Anesthesia / Analgesia frequency*

Moderate Sedation *

Moderate Sedation proficiency*

Moderate Sedation frequency*

Procedures / Equipment

Proficiency Rating

Frequency Rating

Chest Tube Drainage *

Chest Tube Drainage proficiency*

Chest Tube Drainage frequency*

Urinary Catheters *

Urinary CathetersLithotripsy proficiency*

Urinary Catheters frequency*

Suctioning (Oral / Nasal / Pharyngeal) *

Suctioning (Oral / Nasal / Pharyngeal) proficiency*

Suctioning (Oral / Nasal / Pharyngeal) frequency*

Isolation *

Isolation proficiency*

Isolation frequency*

Specialty Beds *

Specialty Beds proficiency*

Specialty Beds frequency*

Universal Precautions *

Universal Precautions proficiency*

Universal Precautions frequency*

Wound Vac *

Wound Vac proficiency*

Wound Vac frequency*

Butterfly Stick *

Butterfly Stick proficiency*

Butterfly Stick frequency*

Venipuncture *

Venipuncture proficiency*

Venipuncture frequency*

Bedside Invasive Procedures *

Bedside Invasive Procedures proficiency*

Bedside Invasive Procedures frequency*

Central Line Insertion *

Central Line Insertion proficiency*

Central Line Insertion frequency*

Lumbar Puncture *

Lumbar Puncture proficiency*

Lumbar Puncture frequency*

Paracentesis *

Paracentesis proficiency*

Paracentesis frequency*

Thoracentesis *

Thoracentesis proficiency*

Thoracentesis frequency*

Other Skills

Proficiency Rating

Frequency Rating

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