Skills Checklist – Medical Surgical

CARE OF PATIENTS WITH*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Abdominal Aortic Aneurysm
Angina
Cardiac Arrest
Cardiogenic Shock
Carotid Endarterectomy
Congestive Heart Failure
Deep Vein Thrombosis
Post Acute MI (>48 hrs)
Post Angioplasty
Fresh Tracheostomy
Pulmonary Edema
Pneumonia
Pneumothorax
CVA/TIA
Head Injuries/Intercranial bleeds
Multiple Sclerosis
Neuromuscular Disease
Seizures
Spinal Cord Injuries
Renal Failure
Hepatic Failure
Hepatitis
Cholecysitis
Bowel Obstruction
GI Bleed
Inflammatory Bowel Disease
Paralytic Ileus
Peritonitis
TURP/TURBP
Amputation
Osteomylelitis
Total Joint Replacement
Adrenal Disorders
Pituitary Disorders
Burns
Delirium Tremens
HIV/AIDS
Post Thyroidectomy

MEDICATION ADMINISTRATION*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Antibiotics
Chemotherapeutic Agents
Digoxin
Heparin
Insulin
Antiarrhythmics
Antihypertensives
Anticoagulants
Oral Hypoglycemics
Reversal Agents
Antipsychotics
Benzodiazepines
Antidepressants
TPN Administration
Inhaled Medications
Patient Controlled Analgesia (PCA)
Blood/Blood Product Administration
Narcotics
CAD Pump
Non-opiod Analgesics
Insulin Pump
Steroids
Automated Medication Dispenser (Pyxis)
Diuretics

PROCEDURES/SKILLS*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
A-V Fistula Care
Brace/Splint Application
Foley/Straight Cath insertion & care
Central line care
Chemotherapy
Chest Tube & Drainage System
CVP Measurment
Cardioversion
Defibrillation
EKG - obtaining 12 lead
EKG arrhythmia interpretation
EKG - lead placement
Continuous Tube Feeding
Glascow Coma Scale
Gastric Lavage, Iced Saline
Gavage, intermittent Tube Feeding
Gastric Suction
Interpretation of Lab Results
Intestinal Tract Tube Insertion/Care
Oxygen Therapy Administration
Pacemaker
Peritoneal Dialysis
Specimen Collection
Suctioning
Temperature
Wound/Ostomy Care
Pressure ulcers

EQUIPMENT*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Automated Med. Dispensing Systems
Pneumatic Stockings
Cardiac/Tele Monitor
Glucometer
Hypo/Hyperthermia blanket
Infusion Pumps
Specialty Beds
Ventilator Management/Troubleshooting

Do you speak any languages other than English?*
- No
If yes, enter languages above, separated by commas.

Age Group Experience*

Confirmation*
- I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
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Date
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