TELE, PCU, STEPDOWN RN

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Name*
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*
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*
Administration of Blood and Blood Products *
Administration of Blood and Blood Products proficiency*
Administration of Blood and Blood Products frequency*
PCA Pumps *
PCA Pumps proficiency*
PCA Pumps frequency*
Infusion Pumps *
Infusion Pumps proficiency*
Infusion Pumps 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*
Moderate / Conscious Sedation & Reversal Agents *
Moderate / Conscious Sedation & Reversal Agents proficiency*
Moderate / Conscious Sedation & Reversal Agents frequency*

IV Therapy
Proficiency Rating
Frequency Rating

Initiate Peripheral IV *
Initiate Peripheral IV proficiency*
Initiate Peripheral IV frequency*
Discontinue Peripheral IV *
Discontinue Peripheral IV proficiency*
Discontinue Peripheral IV frequency*
Central Line Blood Draw *
Central Line Blood Draw proficiency*
Central Line Blood Draw frequency*
Central Line Care & Maintenance *
Central Line Care & Maintenance proficiency*
Central Line Care & Maintenance frequency*
PICC Line Blood Draw *
PICC Line Blood Draw proficiency*
PICC Line Blood Draw frequency*
PICC Line Care & Maintenance *
PICC Line Care & Maintenance proficiency*
PICC Line Care & Maintenance frequency*

Neuro General Skills
Proficiency Rating
Frequency Rating

Assessment of Neuro Signs *
Assessment of Neuro Signs proficiency*
Assessment of Neuro Signs frequency*
Glasgow Coma Scale *
Glasgow Coma Scale proficiency*
Glasgow Coma Scale frequency*
Seizure Precautions *
Seizure Precautions proficiency*
Seizure Precautions frequency*
Assist with Lumbar Puncture *
Assist with Lumbar Puncture proficiency*
Assist with Lumbar Puncture frequency*
Halo Traction *
Halo Traction proficiency*
Halo Traction frequency*
NEURO - CARE OF PATIENTS WITH:
CVA *
CVA proficiency*
CVA frequency*
Seizure Activity *
Seizure Activity proficiency*
Seizure Activity frequency*
Overdose *
Overdose proficiency*
Overdose frequency*
Neuro / Head Injury / Trauma *
Neuro / Head Injury / Trauma proficiency*
Neuro / Head Injury / Trauma frequency*
Pre / Post Neuro Surgery *
Pre / Post Neuro Surgery proficiency*
Pre / Post Neuro Surgery frequency*
Cranial Hemorrhage *
Cranial Hemorrhage proficiency*
Cranial Hemorrhage frequency*
Multiple Sclerosis *
Multiple Sclerosis proficiency*
Multiple Sclerosis frequency*
Post-Op AV Shunt *
Post-Op AV Shunt proficiency*
Post-Op AV Shunt frequency*

Medication Knowledge and Use of
Proficiency Rating
Frequency Rating

Decadron *
Decadron proficiency*
Decadron frequency*
Dilantin *
Dilantin proficiency*
Dilantin frequency*
Magnesium Sulfate *
Magnesium Sulfate proficiency*
Magnesium Sulfate frequency*
Phenobarbital *
Phenobarbital proficiency*
Phenobarbital frequency*
Steroids *
Steroids proficiency*
Steroids frequency*
Valium *
Valium proficiency*
Valium frequency*
Versed *
Versed proficiency*
Versed frequency*

Cardiac General Skills
Proficiency Rating
Frequency Rating

Auscultation of Cardiac Sounds *
Auscultation of Cardiac Sounds proficiency*
Auscultation of Cardiac Sounds frequency*
Dopplers *
Dopplers proficiency*
Dopplers frequency*
Interpretation of 12 lead EKG *
Interpretation of 12 lead EKG proficiency*
Interpretation of 12 lead EKG frequency*
Interpretation of Arrhythmias *
Interpretation of Arrhythmias proficiency*
Interpretation of Arrhythmias frequency*
Defibrillation / cardioversion *
Defibrillation / cardioversion proficiency*
Defibrillation / cardioversion frequency*
Permanent Pacemaker *
Permanent Pacemaker proficiency*
Permanent Pacemaker frequency*
Temporary Pacemaker *
Temporary Pacemaker proficiency*
Temporary Pacemaker frequency*
AICD *
AICD proficiency*
AICD frequency*
Art - Line (transducer set - up, D/C) *
Art - Line (transducer set - up, D/C) proficiency*
Art - Line (transducer set - up, D/C) frequency*
Sheath Removal *
Sheath Removal proficiency*
Sheath Removal frequency*
Interpretation of Cardiac Enzymes *
Interpretation of Cardiac Enzymes proficiency*
Interpretation of Cardiac Enzymes frequency*

Cardiac - Care of Patients with
Proficiency Rating
Frequency Rating

Angina *
Angina proficiency*
Angina frequency*
CHF *
CHF proficiency*
CHF frequency*
Post MI *
Post MI proficiency*
Post MI frequency*
Pre / Post Cardiac Cath *
Pre / Post Cardiac Cath proficiency*
Pre / Post Cardiac Cath frequency*
Pre / Post Cardiac Surgery *
Pre / Post Cardiac Surgery proficiency*
Pre / Post Cardiac Surgery frequency*
Open Sternal Wound (Debridement) *
Open Sternal Wound (Debridement) proficiency*
Open Sternal Wound (Debridement) frequency*
Heart Transplant *
Heart Transplant proficiency*
Heart Transplant frequency*

Medication Knowledge and Use of
Proficiency Rating
Frequency Rating

Atropine *
Atropine proficiency*
Atropine frequency*
Diuretics *
Diuretics proficiency*
Diuretics frequency*
Digoxin *
Digoxin proficiency*
Digoxin frequency*
Dopamine *
Dopamine proficiency*
Dopamine frequency*
Dobutrex *
Dobutrex proficiency*
Dobutrex frequency*
Heparin Drip (Precautions & Maintenance) *
Heparin Drip (Precautions & Maintenance) proficiency*
Heparin Drip (Precautions & Maintenance) frequency*
Inderal *
Inderal proficiency*
Inderal frequency*
Inocor *
Inocor proficiency*
Inocor frequency*
Isuprel *
Isuprel proficiency*
Isuprel frequency*
Lidocaine *
Lidocaine proficiency*
Lidocaine frequency*
Nipride *
Nipride proficiency*
Nipride frequency*
Nitroglycerin *
Nitroglycerin proficiency*
Nitroglycerin frequency*
Pronestyl *
Pronestyl proficiency*
Pronestyl frequency*
Morphine *
Morphine proficiency*
Morphine frequency*
Thrombolytic Agents *
Thrombolytic Agents proficiency*
Thrombolytic Agents frequency*
Magnesium Sulfate *
Magnesium Sulfate proficiency*
Magnesium Sulfate frequency*
Versed *
Versed proficiency*
Versed frequency*
Prep / Titration of Emergency Drugs *
Prep / Titration of Emergency Drugs proficiency*
Prep / Titration of Emergency Drugs frequency*

Respiratory General Skills
Proficiency Rating
Frequency Rating

Establishing an Airway *
Establishing an Airway proficiency*
Establishing an Airway frequency*
Ambu-ing Techniques *
Ambu-ing Techniques proficiency*
Ambu-ing Techniques frequency*
Administration of O2 *
Administration of O2 proficiency*
Administration of O2 frequency*
Chest Tubes *
Chest Tubes proficiency*
Chest Tubes frequency*
Pulse Oximetry *
Pulse Oximetry proficiency*
Pulse Oximetry frequency*
Interpretation of ABG *
Interpretation of ABG proficiency*
Interpretation of ABG frequency*
Use of IPPB *
Use of IPPB proficiency*
Use of IPPB frequency*
Incentive Spirometer *
Incentive Spirometer proficiency*
Incentive Spirometer frequency*
Oral Suctioning *
Oral Suctioning proficiency*
Oral Suctioning frequency*
Nasotracheal Suctioning *
Nasotracheal Suctioning proficiency*
Nasotracheal Suctioning frequency*
ET Suctioning *
ET Suctioning proficiency*
ET Suctioning frequency*

Respiratory Care of Patients with
Proficiency Rating
Frequency Rating

COPD *
COPD proficiency*
COPD frequency*
ARDS *
ARDS proficiency*
ARDS frequency*
Pre / Post Thoracic Surgery *
Pre / Post Thoracic Surgery proficiency*
Pre / Post Thoracic Surgery frequency*
Pulmonary embolism *
Pulmonary embolism proficiency*
Pulmonary embolism frequency*
Pulmonary Edema *
Pulmonary Edema proficiency*
Pulmonary Edema frequency*
Pneumothorax *
Pneumothorax proficiency*
Pneumothorax frequency*
Pneumonia *
Pneumonia proficiency*
Pneumonia frequency*
Inhalation Injuries *
Inhalation Injuries proficiency*
Inhalation Injuries frequency*
Emphysema *
Emphysema proficiency*
Emphysema frequency*
Asthma *
Asthma proficiency*
Asthma frequency*
Lung Transplant *
Lung Transplant proficiency*
Lung Transplant frequency*

Medication Knowledge and Use of:
Proficiency Rating
Frequency Rating

Aminophylline *
Aminophylline proficiency*
Aminophylline frequency*
Corticosteroids *
Corticosteroids proficiency*
Corticosteroids frequency*
Bronchodilators *
Bronchodilators proficiency*
Bronchodilators frequency*

Gastrointestinal General Skills
Proficiency Rating
Frequency Rating

NG Tube Insertion, Care and Maintenance *
NG Tube Insertion, Care and Maintenance proficiency*
NG Tube Insertion, Care and Maintenance frequency*
Gastrostomy Tube *
Gastrostomy Tube proficiency*
Gastrostomy Tube frequency*
Jejunostomy Tube *
Jejunostomy Tube proficiency*
Jejunostomy Tube frequency*
Enterostomal Care *
Enterostomal Care proficiency*
Enterostomal Care frequency*
Tube Feedings *
Tube Feedings proficiency*
Tube Feedings frequency*

Gastrointestinal - Care of Patients with:
Proficiency Rating
Frequency Rating

Pancreatitis *
Pancreatitis proficiency*
Pancreatitis frequency*
G.I. Bleed *
G.I. Bleed proficiency*
G.I. Bleed frequency*
Esophageal Bleeding *
Esophageal Bleeding proficiency*
Esophageal Bleeding frequency*
Bowel Obstruction *
Bowel Obstruction proficiency*
Bowel Obstruction frequency*
Whipple Procedure *
Whipple Procedure proficiency*
Whipple Procedure frequency*
Liver Transplant *
Liver Transplant proficiency*
Liver Transplant frequency*
Paralytic Ileus *
Paralytic Ileus proficiency*
Paralytic Ileus frequency*
E.R.C.P. *
E.R.C.P. proficiency*
E.R.C.P. frequency*

Medication Knowledge and Use of:
Proficiency Rating
Frequency Rating

Antiemetics *
Antiemetics proficiency*
Antiemetics frequency*
TPN / Hyperalimentation *
TPN / Hyperalimentation proficiency*
TPN / Hyperalimentation frequency*

Genitourinary / Renal General Skills
Proficiency Rating
Frequency Rating

Peritoneal Dialysis *
Peritoneal Dialysis proficiency*
Peritoneal Dialysis frequency*
Hemodialysis *
Hemodialysis proficiency*
Hemodialysis frequency*
Foley / Straight Catheter Insertion *
Foley / Straight Catheter Insertion proficiency*
Foley / Straight Catheter Insertion frequency*
GU Irrigations *
GU Irrigations proficiency*
GU Irrigations frequency*
Nephrostomy Tube *
Nephrostomy Tube proficiency*
Nephrostomy Tube frequency*
Suprapubic Tube *
Suprapubic Tube proficiency*
Suprapubic Tube frequency*
Electrolyte Imbalance / Replacement *
Electrolyte Imbalance / Replacement proficiency*
Electrolyte Imbalance / Replacement frequency*

Genitourinary / Renal - Care of Patients with:
Proficiency Rating
Frequency Rating

T.U.R.P. *
T.U.R.P. proficiency*
T.U.R.P. frequency*
Shunts and Fistulas *
Shunts and Fistulas proficiency*
Shunts and Fistulas frequency*
Nephrectomy *
Nephrectomy proficiency*
Nephrectomy frequency*
Renal Transplant *
Renal Transplant proficiency*
Renal Transplant frequency*
Renal Trauma *
Renal Trauma proficiency*
Renal Trauma frequency*
Chronic / Acute Renal Failure *
Chronic / Acute Renal Failure proficiency*
Chronic / Acute Renal Failure frequency*

Gynecology General Skills
Proficiency Rating
Frequency Rating

GYN Exam Prep *
GYN Exam Prep proficiency*
GYN Exam Prep frequency*

Gynecology - Care of Patients with:
Proficiency Rating
Frequency Rating

Ectopic Pregnancy / Ruptured Ectopic Pregnancy *
Ectopic Pregnancy / Ruptured Ectopic Pregnancy proficiency*
Ectopic Pregnancy / Ruptured Ectopic Pregnancy frequency*
Hysterectomy *
Hysterectomy proficiency*
Hysterectomy frequency*
Repair of Cystocele / Rectocele *
Repair of Cystocele / Rectocele proficiency*
Repair of Cystocele / Rectocele frequency*

Orthopedic General Skills
Proficiency Rating
Frequency Rating

Assessment of C/M/S *
Assessment of C/M/S proficiency*
Assessment of C/M/S frequency*
K-Wises / Steinman Pins *
K-Wises / Steinman Pins proficiency*
K-Wises / Steinman Pins frequency*
Removal of Hardware *
Removal of Hardware proficiency*
Removal of Hardware frequency*

Orthopedic - Care of Patients with:
Proficiency Rating
Frequency Rating

Total Joint Replacement *
Total Joint Replacement proficiency*
Total Joint Replacement frequency*
Spica Cast / Body Cast *
Spica Cast / Body Cast proficiency*
Spica Cast / Body Cast frequency*
Amputation *
Amputation proficiency*
Amputation frequency*
Traction *
Traction proficiency*
Traction frequency*
Ortho Trauma *
Ortho Trauma proficiency*
Ortho Trauma frequency*
Laminectomy *
Laminectomy proficiency*
Laminectomy frequency*

Endocrine General Skills
Proficiency Rating
Frequency Rating

Diabetic Teaching *
Diabetic Teaching proficiency*
Diabetic Teachingfrequency*
Blood Glucose Monitoring *
Blood Glucose Monitoring proficiency*
Blood Glucose Monitoring frequency*
ENDOCRINE - CARE OF PATIENTS WITH:
Hyper / Hypoglycemia *
Hyper / Hypoglycemia proficiency*
Hyper / Hypoglycemia frequency*
THIS IS A SUB-HEADING
Insulin (IV, SQ) *
Insulin (IV, SQ) proficiency*
Insulin (IV, SQ) frequency*
D50 *
D50 proficiency*
D50 frequency*

Phlebotomy / IV Therapy
Proficiency Rating
Frequency Rating

Peripheral IV Insertion, Care and Maintenance *
Peripheral IV Insertion, Care and Maintenance proficiency*
Peripheral IV Insertion, Care and Maintenance frequency*
Assisting with Insertion of Central Lines *
Assisting with Insertion of Central Lines proficiency*
Assisting with Insertion of Central Lines frequency*
Care and Maintenance of Central Lines *
Care and Maintenance of Central Lines proficiency*
Care and Maintenance of Central Lines frequency*
Assisting with Insertion of PICC Lines *
Assisting with Insertion of PICC Lines proficiency*
Assisting with Insertion of PICC Lines frequency*
Care and Maintenance of PICC Lines *
Care and Maintenance of PICC Lines proficiency*
Care and Maintenance of PICC Lines frequency*
Assist with IC Cutdown *
Assist with IC Cutdown proficiency*
Assist with IC Cutdown frequency*
Phlebitis *
Phlebitis proficiency*
Phlebitis frequency*

Other
Proficiency Rating
Frequency Rating

Heparin Drip (Precautions and Maintenance) *
Heparin Drip (Precautions and Maintenance) proficiency*
Heparin Drip (Precautions and Maintenance) frequency*
Care of Oncology Patient *
Care of Oncology Patient proficiency*
Care of Oncology Patient frequency*
Chemotherapy Administration *
Chemotherapy Administration proficiency*
Chemotherapy Administration frequency*
Care of Patient with Burns *
Care of Patient with Burns proficiency*
Care of Patient with Burns frequency*
Care of Patient with HIV/AIDS *
Care of Patient with HIV/AIDS proficiency*
Care of Patient with HIV/AIDS frequency*
Hyperbaric Oxygenation *
Hyperbaric Oxygenation proficiency*
Hyperbaric Oxygenation frequency*
Suicide Precautions *
Suicide Precautions proficiency*
Suicide Precautions frequency*
Post Mortem Care *
Post Mortem Cares proficiency*
Post Mortem Cares frequency*

Cardiac Monitors
Proficiency Rating
Frequency Rating

Hewlett - Packard *
Hewlett - Packard proficiency*
Hewlett - Packard frequency*
Spacelab *
Spacelab proficiency*
Spacelab frequency*
Siemens *
Siemens proficiency*
Siemens frequency*
Marquette *
Marquette proficiency*
Marquette frequency*
Mennen *
Mennen proficiency*
Mennen frequency*
Lifecare *
Lifecare proficiency*
Lifecare frequency*
Nihon - Koder *
Nihon - Koder proficiency*
Nihon - Koder frequency*
Other Cardiac Monitors Please List: *
Other Cardiac Monitors Please List: proficiency*
Other Cardiac Monitors Please List: frequency*

Ventilators
Proficiency Rating
Frequency Rating

Bear *
Bear proficiency*
Bear frequency*
Bennett 7200 *
Bennett 7200 proficiency*
Bennett 7200 frequency*
CPAP *
CPAP proficiency*
CPAP frequency*
Emerson *
Emerson proficiency*
Emerson frequency*
Engstrom / Erica *
Engstrom / Erica proficiency*
Engstrom / Erica frequency*
EMV *
EMV proficiency*
EMV frequency*
MA-I *
MA-I proficiency*
MA-I frequency*
MA-II *
MA-II proficiency*
MA-II frequency*
Monihan *
Monihan proficiency*
Monihan frequency*
Ohio 560 *
Ohio 560 proficiency*
Ohio 560 frequency*
PEEP *
PEEP proficiency*
PEEP frequency*
Pressure Pre-Set *
Pressure Pre-Set proficiency*
Pressure Pre-Set frequency*
Servo *
Servo proficiency*
Servo frequency*
Siemens *
Siemens proficiency*
Siemens frequency*
Other Ventilators Monitors Please List: *
Other Ventilators Monitors Please List: proficiency*
Other Ventilators Monitors Please List: frequency*
Certify your information*
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