Skilled Nursing Competency Self Assessment

1 DirectionsPlease circle a value for each question to provide us and the interested facilities with an Assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare Nursing Competency Self Assessment 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0057 Skilled Nursing 1 of 5_____Print Name Last 4 Digits of SS# DateExperience0 Not Applicable1 No Experience2 Some Experience (Require Assistance)3 Intermittent Experience (May Require Assistance)4 Experienced (Performs without Assistance)5 Very Experienced (Able to Teach/Supervise)General SkillsExperienceAdvanced directives0 1 2 3 4 5 Awareness of HCAHPS0 1 2 3 4 5 Patient/family teaching0 1 2 3 4 5 Discharge planning0 1 2 3 4 5UR/medicare review0 1 2 3 4 5 Lift/transfer devices0 1 2 3 4 5 Specialty beds0 1 2 3 4 5 Restrictive devices (restraints)

2 0 1 2 3 4 5 End of life care/palliative care0 1 2 3 4 5 Automated Medication Dispensing System, Pyxis, Omnicell, or other0 1 2 3 4 5 National Patient Safety Goals 0 1 2 3 4 5 Accurate patient identification0 1 2 3 4 5 Effective communication0 1 2 3 4 5 Awareness of patient rights0 1 2 3 4 5 Interpretation & communication of lab values0 1 2 3 4 5 Medication administration0 1 2 3 4 5 Labeling (medications & specimens)0 1 2 3 4 5 Medication reconciliation0 1 2 3 4 5 Anticoagulation therapy0 1 2 3 4 5 Pain Assessment & management0 1 2 3 4 5 Infection control0 1 2 3 4 5 Universal precautions0 1 2 3 4 5 Isolation0 1 2 3 4 5 Minimize risk for falls0 1 2 3 4 5 Prevention of pressure ulcers0 1 2 3 4 5 CardiacExperienceAssessment of heart sounds0 1 2 3 4 5 Identification of arrhythmias (rate/rhythm)

3 0 1 2 3 4 5 Pacemakers/AID s0 1 2 3 4 5 Cardiac arrest/CPR0 1 2 3 4 5 Initials _____ 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0057 Skilled Nursing 2 of 5 Experience0 Not Applicable1 No Experience2 Some Experience (Require Assistance)3 Intermittent Experience (May Require Assistance)4 Experienced (Performs without Assistance)5 Very Experienced (Able to Teach/Supervise)Cardiac - of Patient with:Hypertension0 1 2 3 4 5 Pre/post MI0 1 2 3 4 5 CHF0 1 2 3 4 5 Post cardiac surgery0 1 2 3 4 5 Fluid & electrolyte imbalances0 1 2 3 4 5 Medication AdministrationAnticoagulants0 1 2 3 4 5 Antiarrhythmics0 1 2 3 4 5 Beta blockers0 1 2 3 4 5 Nitroglycerin0 1 2 3 4 5 Diuretics0 1 2 3 4 5 RespiratoryExperienceAssessment/ausculta tion of lung sounds0 1 2 3 4 5 Establishing an airway0 1 2 3 4 5 Chest PT0 1 2 3 4 5 Incentive spirometry0 1

4 2 3 4 5 Supplemental oxygen (cannula, facemask)0 1 2 3 4 5 Tracheostomy care0 1 2 3 4 5 Suctioning (tracheostomy & nasotracheal)0 1 2 3 4 5 Nebulizer use0 1 2 3 4 5 Care of Patient with:Pneumonia0 1 2 3 4 5 Asthma0 1 2 3 4 5 COPD0 1 2 3 4 5 Emphysema0 1 2 3 4 5 Use & Administration of:Bronchodilators0 1 2 3 4 5 Expectorants0 1 2 3 4 5 Corticosteroids0 1 2 3 4 5 Initials _____ 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0057 Skilled Nursing 3 of 5 Experience0 Not Applicable1 No Experience2 Some Experience (Require Assistance)3 Intermittent Experience (May Require Assistance)4 Experienced (Performs without Assistance)5 Very Experienced (Able to Teach/Supervise)GastrointestinalExperien ceNG tube (insertion/removal)0 1 2 3 4 5 Long term feeding tubes (dobhoff/keofeed)0 1 2 3 4 5 Gastrostomy tube0 1 2 3 4 5 Tube feedings0 1 2 3 4 5 Monitoring input/output0 1 2 3 4 5 Care of Patient with.

5 Colostomy/ileostomy0 1 2 3 4 5GI bleed0 1 2 3 4 5 Feeding devices/adaptive equipment0 1 2 3 4 5 Dietary restrictions0 1 2 3 4 5GT/PEG feedings0 1 2 3 4 5 Use & Administration of:Antiemetics0 1 2 3 4 5 Laxatives0 1 2 3 4 5 Enemas0 1 2 3 4 5 Bowel prep0 1 2 3 4 5 NeurologyExperienceAssessment of neuro signs0 1 2 3 4 5 Seizure precautions0 1 2 3 4 5 Care of Patient with:TBI (Traumatic Brain Injury: history of)0 1 2 3 4 5 Seizure activity0 1 2 3 4 5 Spinal cord injury0 1 2 3 4 5 Stroke (CVA)0 1 2 3 4 5 Multiple sclerosis0 1 2 3 4 5 Alzheimer s disease0 1 2 3 4 5 Parkinson s disease0 1 2 3 4 5 ALS (Amyotrophic Lateral Sclerosis)0 1 2 3 4 5 Use & Administration of:Antiseizure medications0 1 2 3 4 5 Antiemetics0 1 2 3 4 5 Laxatives0 1 2 3 4 5 Enemas0 1 2 3 4 5 Bowel prep0 1 2 3 4 5 Initials _____ 2012 Cross Country Healthcare, Inc.

6 Rev. 09/12 F0057 Skilled Nursing 4 of 5 Experience0 Not Applicable1 No Experience2 Some Experience (Require Assistance)3 Intermittent Experience (May Require Assistance)4 Experienced (Performs without Assistance)5 Very Experienced (Able to Teach/Supervise)GenitourinaryExperienceF oley catheter insertion/removal0 1 2 3 4 5GU irrigations0 1 2 3 4 5 Nephrostomy tube0 1 2 3 4 5 Suprapubic catheter0 1 2 3 4 5 Ileo conduit0 1 2 3 4 5 Use of bladder scan equipment0 1 2 3 4 5 Care of Patient with:Shunts and fistulas0 1 2 3 4 5 Straight catheterizations0 1 2 3 4 5 Incontinence/bladder training0 1 2 3 4 5 Chronic renal failure/dialysis0 1 2 3 4 5 Peritoneal dialysis0 1 2 3 4 5 OrthopedicExperienceTotal joint replacement0 1 2 3 4 5 Arthroscopic surgery0 1 2 3 4 5 Cast care0 1 2 3 4 5 Pulse/CMS checks0 1 2 3 4 5 Suture/staple removal0 1 2 3 4 5 Prosthesis application0 1 2 3 4 5 Standard extremity braces0 1 2 3 4 5 Care of Patient with.

7 Amputation0 1 2 3 4 5 Stump wrapping0 1 2 3 4 5 Laminectomy0 1 2 3 4 5 Assistive devices0 1 2 3 4 5 CPM machines0 1 2 3 4 5IV TherapyExperienceStart & maintain IVs0 1 2 3 4 5 Blood draw: venous0 1 2 3 4 5 Central line care (PICC)0 1 2 3 4 5 Blood draw: central line PICC0 1 2 3 4 5 Care & management of ports0 1 2 3 4 5 Infusion pumps0 1 2 3 4 5 Administration of blood/blood products0 1 2 3 4 5 Initials _____ 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0057 Skilled Nursing 5 of 5 The information on this and all preceding pages is true and Signature DateFax to.

8 1-888-298-3146 Experience0 Not Applicable1 No Experience2 Some Experience (Require Assistance)3 Intermittent Experience (May Require Assistance)4 Experienced (Performs without Assistance)5 Very Experienced (Able to Teach/Supervise)SkinExperienceWound care/surgical0 1 2 3 4 5 Wound care/medical0 1 2 3 4 5 Dressing changes0 1 2 3 4 5 Skin assessment0 1 2 3 4 5 Wound vac0 1 2 3 4 5 Age Specific CompetenciesExperienceNewborn/neonate (birth-30 days)0 1 2 3 4 5 Infant (31 days-1 year)0 1 2 3 4 5 Toddler (2-3 years)0 1 2 3 4 5 Preschool (ages 4-5 years)0 1 2 3 4 5 School age (ages 6-12 years)0 1 2 3 4 5 Adolescents (ages 13-21 years)0 1 2 3 4 5 Young adult (ages 22-39 years)0 1 2 3 4 5 Adults (ages 40-64 years)0 1 2 3 4 5 Older adult (ages 65-79 years)0 1 2 3 4 5 Elderly (ages 80+ years)0 1 2 3 4 5 Please list any Additional