Skills Checklist - PT - Origin Travel Nurses

Skills Checklist - PT

Name
First Last
Phone
Email
SETTING*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Acute
Rehab
Inpatient
Outpatient
Home Health
SNF
Schools

ADULT - ORTHOPEDIC:*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Neck Injuries / Surgeries
Back Injuries / Surgeries
Hip Fractures / Injuries
Total Hip Replacement
Knee Injuries
Total Knee Replacement
Upper Extremity Joint Replacements
Shoulder Injuries
Degenerative Joint Disease / Arthritis
Hand Injuries
Temporomandibular Joint (TMJ)
Post Operative Care
Amputations

ADULT - NEUROLOGIC:*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Stroke Rehabilitation
Cognitive Disorders
Head Trauma
Spinal Cord Injury
Functional Splinting
Adaptive Equipment-Wheelchair
Neuromuscular Diseases
Multiple Sclerosis

ADULT - Prosthetics / Orthotics:*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Upper Extremity Prosthetics
Above Knee Prosthetics
Below Knee Prosthetics
SPORTS MEDICINE*
Rarely Some Experience Proficient Trainer / Preceptor N/A
LIDO Machine
Nautilus Machine
Taping

PROCEDURES / TREATMENTS*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Ankle / Foot Orthosis
Slings
Splints - Wrist / Hand
CPM Machine
Hydrotherapy
Whirlpool
Hubbard Tank
Therapeutic Pool
TENS
Electrical Stimulation
Ultrasound
Cryotherapy
Massage
Diathermy
Acupressure
Spinal Mobilization
Extremity Mobilization
Myofacial Release
Craniosacral Techniques
Cervical Traction
Lumbar Traction
Activities of Daily Living
Gait Training
Transfers
Sports Medicine
Athletic Injuries
Biodex
Cybex
Orthotron

OTHER*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Chest PT
Cardiac Rehab
ICU Procedures
CCU Procedures
SICU Procedures
Burn Management
Work Hardening - Work Site Eval
Work Capacity Eval
Functional Capacity Eval
Muscle Energy Techniques
Universal Precautions
Skilled Nursing Documentation
Medicare A
Medicare B
State Healthcare
Electronic Documentation

OTHER - TYPES OF ELECTRONIC DOCUMENTATION:
(if applicable)

Age Group Experience*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Newborn (birth - 30 days)
Infant (30 days - 1 year)
Toddler (1 - 3 years)
Preschooler (3 - 5 years)
School Age (5 - 12 years)
Adolescents (12 - 18 years)
Young Adults (18 - 39 years)
Middle Adults (39-64 years)
Older Adults (64+ years)

Do you speak any languages other than English?*
- No
If yes, enter languages above, separated by commas.
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.
Signature
Date
MM slash DD slash YYYY