Nurse Practitioner 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 independentlyAreas WorkedEmergency(Required) 1 2 3 4 Urgent Care(Required) 1 2 3 4 Private Practice(Required) 1 2 3 4 HMO(Required) 1 2 3 4 MD Office(Required) 1 2 3 4 Schools(Required) 1 2 3 4 Health Department(Required) 1 2 3 4 Ambulatory Clinic(Required) 1 2 3 4 Rural Health Clinic(Required) 1 2 3 4 Psychiatric Facility(Required) 1 2 3 4 Correctional Facility(Required) 1 2 3 4 Mobile Medical Unit(Required) 1 2 3 4 Corporate Worksite(Required) 1 2 3 4 Occupational Health(Required) 1 2 3 4 Rehabilitation(Required) 1 2 3 4 Nursing Home/ Long-term Care Facility(Required) 1 2 3 4 Women's Health Clinic(Required) 1 2 3 4 Government Health Agency(Required) 1 2 3 4 Hospice/Palliative Care(Required) 1 2 3 4 Experience WithDiabetes(Required) 1 2 3 4 Contractures(Required) 1 2 3 4 Bedridden residents(Required) 1 2 3 4 Splinting of extremities(Required) 1 2 3 4 Local infiltration(Required) 1 2 3 4 Comprehensive physical assessment(Required) 1 2 3 4 Acute disease condition(Required) 1 2 3 4 Differential diagnosis(Required) 1 2 3 4 Order, may perform, & interpret screening & diagnostic test(Required) 1 2 3 4 Central line management(Required) 1 2 3 4 Disorders – EmergenciesAnaphylaxis(Required) 1 2 3 4 Cardiac arrest(Required) 1 2 3 4 Seizures(Required) 1 2 3 4 Minor head injuries(Required) 1 2 3 4 Animal bites(Required) 1 2 3 4 Ingestions and poisonings(Required) 1 2 3 4 Overdose of sedative, hypnotics, opiates(Required) 1 2 3 4 Snake bites(Required) 1 2 3 4 Minor burns(Required) 1 2 3 4 Shock(Required) 1 2 3 4 Open wounds(Required) 1 2 3 4 CollaborationFamily, support system, community resources(Required) 1 2 3 4 Consulting with Physicians(Required) 1 2 3 4 Consulting with Pharmacists(Required) 1 2 3 4 Consulting with Speech Therapist(Required) 1 2 3 4 Consulting with Dietician and Diet Aide(Required) 1 2 3 4 Consulting with Occupational Therapist(Required) 1 2 3 4 Referral to Pastoral Services(Required) 1 2 3 4 RespiratoryCroup(Required) 1 2 3 4 Influenza(Required) 1 2 3 4 Tracheobronchitis(Required) 1 2 3 4 Bronchitis(Required) 1 2 3 4 COPD (chronic obstructive pulmonary disease)(Required) 1 2 3 4 Asthma(Required) 1 2 3 4 URI (upper respiratory infection)(Required) 1 2 3 4 Obstructive Sleep Apnea(Required) 1 2 3 4 PneumoniaViral(Required) 1 2 3 4 Bacterial(Required) 1 2 3 4 SinusitisNonbacteria(Required) 1 2 3 4 Oxygen administration(Required) 1 2 3 4 Liquid oxygen(Required) 1 2 3 4 IPPB machine use(Required) 1 2 3 4 Tracheotomies(Required) 1 2 3 4 Interpret ABG (blood gases)(Required) 1 2 3 4 Intubations(Required) 1 2 3 4 Sputum Collection(Required) 1 2 3 4 Cardiovascular SystemCongestive heart failure(Required) 1 2 3 4 Chronic obstructive pulmonary disease(Required) 1 2 3 4 Stasis ulcer of lower extremities(Required) 1 2 3 4 Angina(Required) 1 2 3 4 Pericarditis(Required) 1 2 3 4 Coronary artery disease(Required) 1 2 3 4 Functional murmurs(Required) 1 2 3 4 Congenital heart disease(Required) 1 2 3 4 Hypertension(Required) 1 2 3 4 ASHD (arteriosclerotic heart disease)(Required) 1 2 3 4 Dyslipidemia(Required) 1 2 3 4 PVD (peripheral vascular disease)(Required) 1 2 3 4 Peripheral neuropathy(Required) 1 2 3 4 Interpreting 12 lead EKG’s(Required) 1 2 3 4 OB/GYNCandida vaginitis(Required) 1 2 3 4 Dysmenorrhea(Required) 1 2 3 4 Abnormal pap smear findings(Required) 1 2 3 4 Pap smears(Required) 1 2 3 4 Trichomonal vaginitis(Required) 1 2 3 4 Atrophic vaginitis(Required) 1 2 3 4 Fibrocystic breast disease(Required) 1 2 3 4 Menopause(Required) 1 2 3 4 Intrapartum medications(Required) 1 2 3 4 Bartholin's cyst/abscess(Required) 1 2 3 4 Preparation for childbirth(Required) 1 2 3 4 Pregnancy - diagnosis and referral(Required) 1 2 3 4 Pain relief in active phase of labor(Required) 1 2 3 4 Medications in the third stage(Required) 1 2 3 4 Dysfunctional uterine bleeding(Required) 1 2 3 4 Medications in the postpartum phase(Required) 1 2 3 4 Rh blood factor(Required) 1 2 3 4 Mastitis(Required) 1 2 3 4 Birth control methods(Required) 1 2 3 4 Prenatal care(Required) 1 2 3 4 Fetal well-being(Required) 1 2 3 4 Nausea and vomiting with pregnancy(Required) 1 2 3 4 Pap smears(Required) 1 2 3 4 Pregnancy test kits(Required) 1 2 3 4 GI SystemConstipation(Required) 1 2 3 4 Diarrhea (simple)(Required) 1 2 3 4 Acute gastroenteritis(Required) 1 2 3 4 Cholecystitis(Required) 1 2 3 4 Pyloric stenosis(Required) 1 2 3 4 Colic(Required) 1 2 3 4 Appendicitis(Required) 1 2 3 4 Naso-gastric tubes(Required) 1 2 3 4 Gastrostomy Care(Required) 1 2 3 4 SkinWarts(Required) 1 2 3 4 Basal cell carcinoma(Required) 1 2 3 4 Scabies(Required) 1 2 3 4 Impetigo(Required) 1 2 3 4 Diaper dermatitis(Required) 1 2 3 4 Acne(Required) 1 2 3 4 Folliculitis(Required) 1 2 3 4 Furuncles(Required) 1 2 3 4 Carbuncles(Required) 1 2 3 4 Herpes Simplex(Required) 1 2 3 4 Herpes Zoster(Required) 1 2 3 4 Malignant melanoma(Required) 1 2 3 4 Pityriasis Rosea(Required) 1 2 3 4 Contact dermatitis(Required) 1 2 3 4 Tinea corporis(Required) 1 2 3 4 Tinea pedis(Required) 1 2 3 4 Staph infections(Required) 1 2 3 4 Wound care(Required) 1 2 3 4 Single layer wound closure(Required) 1 2 3 4 Incision and drainage(Required) 1 2 3 4 Excisions(Required) 1 2 3 4 Ears, Nose and ThroatEpistaxis(Required) 1 2 3 4 Otitis externa(Required) 1 2 3 4 Serous otitis media(Required) 1 2 3 4 Acute purulent otitis media(Required) 1 2 3 4 Allergic rhinitis(Required) 1 2 3 4 Pharyngitis(Required) 1 2 3 4 Oral candidiasis(Required) 1 2 3 4 EyeConjunctivitis(Required) 1 2 3 4 Strabismus(Required) 1 2 3 4 Chalazion(Required) 1 2 3 4 Stye(Required) 1 2 3 4 Visual acuity(Required) 1 2 3 4 Fluorescein staining of eyes(Required) 1 2 3 4 Audiometry(Required) 1 2 3 4 Tympanometry(Required) 1 2 3 4 MusculoskeletalOsteoporosis(Required) 1 2 3 4 Osteomyelitis(Required) 1 2 3 4 Rheumatoid arthritis(Required) 1 2 3 4 Juvenile diabetes(Required) 1 2 3 4 Gout(Required) 1 2 3 4 Minor sprains and strains(Required) 1 2 3 4 Osteoarthritis(Required) 1 2 3 4 Carpal tunnel syndrome(Required) 1 2 3 4 Scoliosis(Required) 1 2 3 4 Tendonitis(Required) 1 2 3 4 Muscular dystrophy(Required) 1 2 3 4 Parasitic InfectionsPinworms(Required) 1 2 3 4 Ascariasis(Required) 1 2 3 4 Pediculosis(Required) 1 2 3 4 Genitourinary SystemSyphilis(Required) 1 2 3 4 Chlamydia(Required) 1 2 3 4 Herpes(Required) 1 2 3 4 Cystitis(Required) 1 2 3 4 Pyelonephritis(Required) 1 2 3 4 Urinary tract infection(Required) 1 2 3 4 Benign prostatic hypertrophy(Required) 1 2 3 4 Vulvovaginitis(Required) 1 2 3 4 Hypospadias(Required) 1 2 3 4 Hydrocele(Required) 1 2 3 4 Gonococcal infections(Required) 1 2 3 4 Prostatitis(Required) 1 2 3 4 Catheter Care(Required) 1 2 3 4 Incontinence care-bowel(Required) 1 2 3 4 Dermal ulcers(Required) 1 2 3 4 Enemas/ Suppositories/ Fecal(Required) 1 2 3 4 Urine collection(Required) 1 2 3 4 Nervous SystemVasovagal syncope(Required) 1 2 3 4 Migraine headaches(Required) 1 2 3 4 Multiple sclerosis(Required) 1 2 3 4 Headaches(Required) 1 2 3 4 Head injury(Required) 1 2 3 4 Tension(Required) 1 2 3 4 Anxiety(Required) 1 2 3 4 Parkinson’s(Required) 1 2 3 4 Alzheimer’s(Required) 1 2 3 4 Bell’s Palsy(Required) 1 2 3 4 TIA (transient ischemic attacks)(Required) 1 2 3 4 Trigeminal neuralgia(Required) 1 2 3 4 EndocrineType I diabetes mellitus(Required) 1 2 3 4 Type II diabetes mellitus(Required) 1 2 3 4 Graves disease(Required) 1 2 3 4 Addison's disease(Required) 1 2 3 4 Juvenile diabetes(Required) 1 2 3 4 Hypoglycemia(Required) 1 2 3 4 Hypothyroidism(Required) 1 2 3 4 HematologicalFolic acid deficiency anemia(Required) 1 2 3 4 Aplastic anemia(Required) 1 2 3 4 Iron deficiency(Required) 1 2 3 4 Sickle cell anemia(Required) 1 2 3 4 Pernicious anemia(Required) 1 2 3 4 Hemoglobinmeter(Required) 1 2 3 4 PsychosocialDepression(Required) 1 2 3 4 Suicide(Required) 1 2 3 4 Obesity(Required) 1 2 3 4 Grief(Required) 1 2 3 4 Anxiety(Required) 1 2 3 4 Anorexia(Required) 1 2 3 4 Bulimia(Required) 1 2 3 4 Drug TherapyPrescription(Required) 1 2 3 4 Over the counter (OTC)(Required) 1 2 3 4 Herbal drugs(Required) 1 2 3 4 Knowledge of pharmacology(Required) 1 2 3 4 Knowledge of pharmacokinetics(Required) 1 2 3 4 Knowledge of drug interactions(Required) 1 2 3 4 Knowledge of side effects(Required) 1 2 3 4 Knowledge of potential adverse reactionsAllergic reactions(Required) 1 2 3 4 Anaphylaxis reaction(Required) 1 2 3 4 TPN/Lipid Management(Required) 1 2 3 4 Management/Titration of IV Therapies(Required) 1 2 3 4 IV/PO Antibiotic Therapy and understanding of cultures(Required) 1 2 3 4 Dispensing MedicationMonitoring drug therapy(Required) 1 2 3 4 Management of controlled substances(Required) 1 2 3 4 Injections(Required) 1 2 3 4 InjectionsMedical nutrition therapy(Required) 1 2 3 4 Exercise(Required) 1 2 3 4 Cessation of substance abuse (alcohol, tobacco)(Required) 1 2 3 4 Mental health issues (stress management, depression)(Required) 1 2 3 4 Obesity management(Required) 1 2 3 4 Tube Feeding Management(Required) 1 2 3 4 AuthorizationsPublic health and health promotion(Required) 1 2 3 4 Research(Required) 1 2 3 4 Quality assurance(Required) 1 2 3 4 Leadership and teaching skills(Required) 1 2 3 4 Legal and ethical issues(Required) 1 2 3 4 Confidentiality(Required) 1 2 3 4 Cultural awareness(Required) 1 2 3 4 Self evaluation to improve patient care(Required) 1 2 3 4 Continuing education(Required) 1 2 3 4 Working within scope of practice(Required) 1 2 3 4 Discharge planning / collaboration(Required) 1 2 3 4 Suturing(Required) 1 2 3 4 Cell biopsy(Required) 1 2 3 4 Starting IV(Required) 1 2 3 4 Casting and splinting(Required) 1 2 3 4 Radiographic interpretation (initial)(Required) 1 2 3 4 Informed consent(Required) 1 2 3 4 Explanation to patient/family(Required) 1 2 3 4 Documentation(Required) 1 2 3 4 Venipuncture(Required) 1 2 3 4 Ultrasounds(Required) 1 2 3 4 ProgramsOSHA (Occupational Safety and Health Administration)(Required) 1 2 3 4 Medicare and Medicaid(Required) 1 2 3 4 CLIA waiver (Clinical Laboratory Improvement Amendments)(Required) 1 2 3 4 TJC (The Joint Commission)(Required) 1 2 3 4 HEDIS (Health Plan Employer Data and Information Set)(Required) 1 2 3 4 DQIP (Diabetes Quality Improvement Program)(Required) 1 2 3 4 HIPAA (Health Insurance Portability & Accountability Act)(Required) 1 2 3 4 HCAHPS(Required) 1 2 3 4 Age Specific CompetenciesNewborn/neonate (birth-30 days)(Required) 1 2 3 4 Infant (31 days-1 year)(Required) 1 2 3 4 Toddler (ages 2-3 years)(Required) 1 2 3 4 Preschool (ages 4-5 years)(Required) 1 2 3 4 School age (ages 6-12 years)(Required) 1 2 3 4 Adolescents (ages 13-21 years)(Required) 1 2 3 4 Young adult (ages 22-39 years)(Required) 1 2 3 4 Adults (ages 40-64 years)(Required) 1 2 3 4 Older adult (ages 65-79 years)(Required) 1 2 3 4 Elderly (ages 80+ years)(Required) 1 2 3 4 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. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
