Ambulatory Skills Checklist
   NAME  
   Email-Id
   DATE    
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions:

This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

 
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

 
Rating Stars (Click)
General Patient Care 1
2
3
4
Admit and Assess Patients
Advance Directives
Collect Appropriate Data
Discharge Teaching
Preoperative Teaching
Patient Prep
Computerized Documentation
Rating Stars (Click)
Cardiovascular 1
2
3
4
Assess Heart Tones
Bedside Tele Monitoring
Interpretation of Coagulation Studies
Perform Pulses/Circulation Checks
Pre/Post Op Care Pacemaker
Rating Stars (Click)
Pulmonary 1
2
3
4
Assess Breath Sounds
Apply Oxygen
Interpret ABGs
Thoracentesis
Oximetry
Rating Stars (Click)
Neurology 1
2
3
4
Assess Neurological Signs
Epidurals
Selective Nerve Root Blocks
Level of Consciousness
Rating Stars (Click)
GI 1
2
3
4
Insertion/Monitoring NG Tubes
Assessment/Patient Care Continued
Flexible Sigmoidoscopy
Hemorrhoid Banding
Liver Biopsy
Paracentesis
Lap Band Surgery
Rating Stars (Click)
GU 1
2
3
4
Bladder Biopsy
Cystoscopy
Urethral Dilation
Nephrostomy
Kidney Biopsy
Suprapubic Catheter
Prostate Biopsy
Rating Stars (Click)
Endocrine 1
2
3
4
Care of Diabetic Patient
Diabetic Teaching
Rating Stars (Click)
ENT and Mouth 1
2
3
4
Prosthondontics – Restorative Dentistry
Mouth Biopsy
Myringotomy
Maxillofacial Prosthetics
Nose Biopsy
Thyroid Aspirate Biopsy
Fiberoptic Laryngoscopy
Tonsilectomy
Rhinoplasty
Rating Stars (Click)
Wounds/Integument 1
2
3
4
Application of Burn Dressings
Application of Dressing
Debridement of Wound
Wound Care
Rating Stars (Click)
OB/GYN 1
2
3
4
Electrodesiccation and Curettage (ED&C)
Nipple Reconstruction
Rating Stars (Click)
Musculoskeletal 1
2
3
4
Arthrocentesis
External Hardware and Pin Care
Arthroscopy
Open Reduction and Internal Fixation
Closed Reduction and Internal Fixation
Trigger Point Injections
Rating Stars (Click)
Plastics 1
2
3
4
Liposuction
Plastic Surgery
Cosmetic
Rating Stars (Click)
General Medications/Therapeutic Interventions 1
2
3
4
Administer IM and SQ Meds
Administer Inhalation Medications
Administer PO Medications
Bladder Irrigation and Instillation
Needleless Systems
Chemotherapy
Rating Stars (Click)
IV Therapy 1
2
3
4
Infusion Pumps
Peipheral IV Insertion
Syringe Pumps
Vascular Access Devices Care/Maintenance
Administer IV Medications
Rating Stars (Click)
Oxygen Administration 1
2
3
4
Ambu-Bug
Nasal Cannula
Non-ReBreather Mask
Pulse Oximetry
Venti Mask
Face Mask
Rating Stars (Click)
Nutritional Therapy 1
2
3
4
Lipids
TPN
Procalamine
Enteral Administration
Rating Stars (Click)
Pain Management/Anesthesia 1
2
3
4
Inplantable Narcotic Pump Re ll
Moderate Sedation
Epidural
Spinal
Local
General
Axillary Block
Bier Block
Rating Stars (Click)
Blood 1
2
3
4
Blood and Blood Products
Albumin
Rating Stars (Click)
General Procedures/Equipment 1
2
3
4
Apply Immobilizers (clavicle, knee, etc.)
Assist with Code Resuscitation
Assist with Lumbar Puncture
Laser
Dermabrasion
Drain Removal
Incision and Drainage
NGT Insertion
Patch Test
Punch Biopsy
Procedure Set Up
Procedures/Equipment Continued
Remove External Fixators With Pin
Scissor Biopsy
Scrub
Screw-Hardware Removal
Set-up Assist Suturing
Staple Removal
Straight/Foley Cath Female
Straight/Foley Cath Male
Suture Removal
TENS (Transcutaneous Elec. Nerve Stimulator)
Use of Doppler
Rating Stars (Click)
Specimen Collections 1
2
3
4
Venipuncture
Clean Catch Urine
Sterile Urine Collection
Stool
Sputum
Butter y Stick
Central Line Draw
Rating Stars (Click)
Clinical Settings 1
2
3
4
Surgi-Center
Out Patient Clinic
Age Group Experience Continued
Physician O ce
Ambulatory Surgery Clinic
Rating Stars (Click)
Joint Commission 1
2
3
4
National Safety Goals
“Do Not Use” Abbreviations and Terms
Rating Stars (Click)
Age Specific Competencies 1
2
3
4
Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)
Elderly (ages 80+ years)