Home Health Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information HiddenOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security Number Email(Required) HiddenDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyCARDIOVASCULARACS/Post MI(Required) 1 2 3 4 Heart Failure(Required) 1 2 3 4 Post Cardiac Surgery(Required) 1 2 3 4 Cardiac Auscultation (Rate/Rhythm)(Required) 1 2 3 4 Peripheral Pulse/Circulation Checks(Required) 1 2 3 4 PULMONARYAsthma(Required) 1 2 3 4 COPD(Required) 1 2 3 4 Pneumonia(Required) 1 2 3 4 Lung Cancer(Required) 1 2 3 4 Pulmonary Emboli(Required) 1 2 3 4 Auscultate Lung Sounds(Required) 1 2 3 4 Oxygen Administration(Required) 1 2 3 4 Oxygen Safety(Required) 1 2 3 4 Oro/Nasotracheal Suctioning(Required) 1 2 3 4 CPAP/BiPAP(Required) 1 2 3 4 Ventilator Management(Required) 1 2 3 4 (Specify): NEUROLOGICALCVA(Required) 1 2 3 4 Alzheimer's Disease/Dementia(Required) 1 2 3 4 Degenerative Neurologic Disorders (ALS, MS, etc.)(Required) 1 2 3 4 Brain Tumor(Required) 1 2 3 4 Brain Injury(Required) 1 2 3 4 Para/Quadriplegia(Required) 1 2 3 4 Seizure Disorder(Required) 1 2 3 4 Level of Consciousness/Neuro Changes(Required) 1 2 3 4 ORTHOPEDICSJoint Replacement(Required) 1 2 3 4 DVT Prophylaxis/Recognition(Required) 1 2 3 4 Incision Checks(Required) 1 2 3 4 Staple Removal(Required) 1 2 3 4 Fractures(Required) 1 2 3 4 Cast/Brace(Required) 1 2 3 4 Amputation(Required) 1 2 3 4 Arthritis(Required) 1 2 3 4 In Home PT/INR(Required) 1 2 3 4 Assistive Equipment/Lift Devices(Required) 1 2 3 4 (Specify): GASTROINTESTINALNutritional Assessment(Required) 1 2 3 4 Colostomy/Ileostomy Management(Required) 1 2 3 4 Fecal Incontinence/Diarrhea(Required) 1 2 3 4 Bowel Obstruction(Required) 1 2 3 4 GI Bleed(Required) 1 2 3 4 Post GI Surgery(Required) 1 2 3 4 Hepatitis Liver Failure(Required) 1 2 3 4 NG Tubes(Required) 1 2 3 4 Feeding Tubes(Required) 1 2 3 4 Drainage Devices(Required) 1 2 3 4 Feeding Pumps(Required) 1 2 3 4 (Specify): RENAL/GENITOURINARYHemodialysis(Required) 1 2 3 4 AV Fistula/Shunt(Required) 1 2 3 4 Peritoneal Dialysis(Required) 1 2 3 4 Post Bladder Surgery(Required) 1 2 3 4 Post Prostate Surgery(Required) 1 2 3 4 Urostomy(Required) 1 2 3 4 Urinary Incontinence(Required) 1 2 3 4 Bladder Catheter Insertion/Maintenance(Required) 1 2 3 4 Suprapubic Catheter Insertion/Maintenance(Required) 1 2 3 4 ENDOCRINE/METABOLICDiabetes(Required) 1 2 3 4 Hyper/Hypoglycemia(Required) 1 2 3 4 Diabetic Skin Assessment(Required) 1 2 3 4 Cushing's / Addison's Disease(Required) 1 2 3 4 Thyroid Disease(Required) 1 2 3 4 Insulin Pumps(Required) 1 2 3 4 Glucometers(Required) 1 2 3 4 WOUND/SKIN CAREBraden Scale(Required) 1 2 3 4 Pressure Ulcer Prevention(Required) 1 2 3 4 Pressure Ulcer Staging(Required) 1 2 3 4 Pressure Ulcer Management(Required) 1 2 3 4 Burns(Required) 1 2 3 4 Wound Care(Required) 1 2 3 4 Wound Cultures(Required) 1 2 3 4 Wound Vac(Required) 1 2 3 4 ONCOLOGYRisk for Infection(Required) 1 2 3 4 Symptom Management(Required) 1 2 3 4 Side Effects of Treatment(Required) 1 2 3 4 Terminal Disease(Required) 1 2 3 4 INFECTIOUS DISEASEMRSA(Required) 1 2 3 4 VRE(Required) 1 2 3 4 C. Difficile(Required) 1 2 3 4 HIV(Required) 1 2 3 4 Tuberculosis(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 PHLEBOTOMY/IV THERAPYPeripheral Venipuncture for Labs(Required) 1 2 3 4 Start Ivs(Required) 1 2 3 4 Peripheral Ivs(Required) 1 2 3 4 PICC/CVP Lines(Required) 1 2 3 4 Venous Access Ports(Required) 1 2 3 4 Infusion Pump Set up and Management(Required) 1 2 3 4 Infusion Pump Type:(Required) 1 2 3 4 Specify: PSYCHIATRICCognitive Disorders(Required) 1 2 3 4 Mood Disorders(Required) 1 2 3 4 Schizophrenia/Psychotic Disorders(Required) 1 2 3 4 Medication Compliance(Required) 1 2 3 4 WOMEN'S HEALTH/MATERNAL-INFANT CAREPregnancy Related Complications(Required) 1 2 3 4 Fetal Heart Tones(Required) 1 2 3 4 Contractions(Required) 1 2 3 4 Post Partum Mother/Baby Visit(Required) 1 2 3 4 Newborn Care(Required) 1 2 3 4 Phototherapy(Required) 1 2 3 4 Breast Feeding Support(Required) 1 2 3 4 PEDIATRICSGrowth and Development(Required) 1 2 3 4 Respiratory Distress Syndrome(Required) 1 2 3 4 Bronchopulmonary Dysplasia(Required) 1 2 3 4 Cystic Fibrosis(Required) 1 2 3 4 Muscular Dystrophy(Required) 1 2 3 4 Spina Bifida(Required) 1 2 3 4 Spinal Surgery(Required) 1 2 3 4 Sickle Cell Disease(Required) 1 2 3 4 Trach Care/Suctioning(Required) 1 2 3 4 Ventilator Management(Required) 1 2 3 4 Ventilator Type(Required) 1 2 3 4 (Specify): PAIN MANAGEMENTVerbal/Nonverbal Pain Scales(Required) 1 2 3 4 Response to Pain Management Interventions(Required) 1 2 3 4 PCA Pump(Required) 1 2 3 4 Epidural Cath/Site Monitoring/Pump(Required) 1 2 3 4 Non-Pharmacologic Pain Measures(Required) 1 2 3 4 PALLIATIVE AND END OF LIFE CAREPalliative Symptom Management(Required) 1 2 3 4 Pain Management/Response(Required) 1 2 3 4 Family Support/Teaching(Required) 1 2 3 4 After Death Protocols(Required) 1 2 3 4 MEDICATIONSAlzheimer's Medications(Required) 1 2 3 4 Antiarrhythmics(Required) 1 2 3 4 Antibiotics/Antivirals(Required) 1 2 3 4 Anti-Depressants(Required) 1 2 3 4 Anti-Hypertensives(Required) 1 2 3 4 Anti-Psychotics(Required) 1 2 3 4 Anti-Seizure Medications(Required) 1 2 3 4 Benzodiazepines(Required) 1 2 3 4 Calculation of Pediatric Dosages(Required) 1 2 3 4 Coumadin(Required) 1 2 3 4 Diuretics(Required) 1 2 3 4 Enoxaparin(Required) 1 2 3 4 Inhaled Medications(Required) 1 2 3 4 Nebulizer Medications(Required) 1 2 3 4 Insulin(Required) 1 2 3 4 Opioid and Non-Opioid Analgesics(Required) 1 2 3 4 Oral Chemotherapy(Required) 1 2 3 4 Oral Hypoglycemics(Required) 1 2 3 4 Oral & Topics Nitrates(Required) 1 2 3 4 Rivaroxaban(Required) 1 2 3 4 Sedative/Hypnotics(Required) 1 2 3 4 Steroids(Required) 1 2 3 4 HOME HEALTHIntake/Admissions(Required) 1 2 3 4 Case Manager(Required) 1 2 3 4 Case Load - Pts/Day(Required) 1 2 3 4 (specify) Supervise LVNs/HHAs(Required) 1 2 3 4 Medicare/Medicaid(Required) 1 2 3 4 Long/Short Term Disability(Required) 1 2 3 4 Private Insurance(Required) 1 2 3 4 Telephonic Assessments(Required) 1 2 3 4 Management of Complaints(Required) 1 2 3 4 APS Reports(Required) 1 2 3 4 OASIS(Required) 1 2 3 4 Diagnosis Coding(Required) 1 2 3 4 Document Plan of Care(Required) 1 2 3 4 Clinical Assessment Documentation(Required) 1 2 3 4 PROFESSIONAL KNOWLEDGE AND SKILLSNational Patient Safety Goals/Core Measures(Required) 1 2 3 4 Safety Assessment(Required) 1 2 3 4 Fall Assessment and Prevention(Required) 1 2 3 4 Patient/Family Teaching(Required) 1 2 3 4 Age Specific/Population Based Care(Required) 1 2 3 4 EMRAllscripts(Required) 1 2 3 4 Cerner(Required) 1 2 3 4 Epic(Required) 1 2 3 4 HomeCare Home Base(Required) 1 2 3 4 McKesson(Required) 1 2 3 4 Meditech(Required) 1 2 3 4 EMR Conversion(Required) Yes No Age Specific CompetenciesInfant (Birth - 1 year)(Required) 1 2 3 4 Preschooler (ages 2-5 years)(Required) 1 2 3 4 Childhood (ages 6-12 years)(Required) 1 2 3 4 Adolescents (ages 13-21 years)(Required) 1 2 3 4 Young Adults (ages 22-39 years)(Required) 1 2 3 4 Adults (ages 40-64 years)(Required) 1 2 3 4 Older Adults (ages 65-79 years)(Required) 1 2 3 4 Elderly (ages 80+ years)(Required) 1 2 3 4 CERTIFICATIONSBLS(Required) Yes No BLS Expiry Date ACLS(Required) Yes No ACLS Expiry Date PALS(Required) Yes No PALS Expiry Date IV Certification(Required) Yes No IV Certification Expiry Date Other Other Expiry Date AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. 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