GENERAL INFORMATION

Note: * Denotes a required field.

Please enter your full name as it appears on your Social Security Card: First Name   Middle Name   Last Name  * Please enter the Last Four digits of your Social Security Number:  -   -   *       Please check here if you do not hold a valid social security card. Please provide your contact information: Phone Number  * E-mail Address  * Confirm E-mail Address  * Type your e-mail address again above.

This profile is for use by healthcare professionals in the Home Health discipline and specialty. It will not be a determining factor for the program.

CHECKLIST INSTRUCTIONS

Please mark your level of experience      1. No theory and/or experience      2. Limited experience/need supervision and/or support      3. Experienced/minimal support needed to perform      4. Proficient/can perform independently

CARDIOVASCULAR

1

2

3

4

ACS/Post MI

Heart Failure

Post Cardiac Surgery

Cardiac Auscultation (Rate/Rhythm)

Peripheral Pulse/Circulation Checks

PULMONARY

1

2

3

4

Asthma

COPD

Pneumonia

Lung Cancer

Pulmonary Emboli

Auscultate Lung Sounds

Oxygen Administration

Oxygen Safety

Oro/Nasotracheal Suctioning

CPAP/BiPAP

Ventilator Management (Specify):

NEUROLOGICAL

1

2

3

4

CVA

Alzheimer's Disease/Dementia

Parkinson's

Degenerative Neurologic Disorders (ALS, MS, etc.)

Brain Tumor

Brain Injury

Para/Quadriplegia

Seizure Disorder

Level of Consciousness/Neuro Changes

ORTHOPEDICS

1

2

3

4

Joint Replacement

DVT Prophylaxis/Recognition

Incision Checks

Staple Removal

Fractures

Cast/Brace

Amputation

Arthritis

Assistive Equipment/Lift Devices

In Home PT/INR

GASTROINTESTINAL

1

2

3

4

Nutritional Assessment

Colostomy/Ileostomy Management

Fecal Incontinence/Diarrhea

Bowel Obstruction

GI Bleed

Post GI Surgery

Hepatitis Liver Failure

NG Tubes

Feeding Tubes

Feeding Pumps

Drainage Devices

RENAL/GENITOURINARY

1

2

3

4

Hemodialysis

AV Fistula/Shunt

Peritoneal Dialysis

Post Bladder Surgery

Post Prostate Surgery

Urostomy

Urinary Incontinence

Bladder Catheter Insertion/Maintenance

Suprapubic Catheter Insertion/Maintenance

ENDOCRINE/METABOLIC

1

2

3

4

Diabetes

Hyper/Hypoglycemia

Diabetic Skin Assessment

Cushing's / Addison's Disease

Thyroid Disease

Insulin Pumps

Glucometers

WOUND/SKIN CARE

1

2

3

4

Braden Scale

Pressure Ulcer Prevention

Pressure Ulcer Staging

Pressure Ulcer Management

Burns

Wound Care

Wound Cultures

Wound Vac

ONCOLOGY

1

2

3

4

Risk for Infection

Symptom Management

Side Effects of Treatment

Terminal Disease

INFECTIOUS DISEASE

1

2

3

4

MRSA

VRE

C. Difficile

HIV

Tuberculosis

Isolation Precautions

PHLEBOTOMY/IV THERAPY

1

2

3

4

Peripheral Venipuncture for Labs

Start IVs

Peripheral IVs

PICC/CVP Lines

Venous Access Ports

Infusion Pump Set up and Management

Specify Infusion Pump Type:

PSYCHIATRIC

1

2

3

4

Cognitive Disorders

Mood Disorders

Schizophrenia/Psychotic Disorders

Medication Compliance

WOMEN'S HEALTH/MATERNAL-INFANT CARE

1

2

3

4

Pregnancy Related Complications

Fetal Heart Tones

Contractions

Post Partum Mother/Baby Visit

Newborn Care

Phototherapy

Breast Feeding Support

PEDIATRICS

1

2

3

4

Growth and Development

Respiratory Distress Syndrome

Bronchopulmonary Dysplasia

Cystic Fibrosis

Muscular Dystrophy

Spina Bifida

Spinal Surgery

Sickle Cell Disease

Trach Care/Suctioning

Ventilator Management

Ventilator Type (Specify):

PAIN MANAGEMENT

1

2

3

4

Verbal/Nonverbal Pain Scales

Response to Pain Management Interventions

PCA Pump

Epidural Cath/Site Monitoring/Pump

Non-Pharmacologic Pain Measures

PALLIATIVE AND END OF LIFE CARE

1

2

3

4

Palliative Symptom Management

Pain Management/Response

Family Support/Teaching

After Death Protocols

MEDICATIONS

1

2

3

4

Alzheimer's Medications

Antiarrhythmics

Antibiotics/Antivirals

Anti-Depressants

Anti-Hypertensives

Anti-Psychotics

Anti-Seizure Medications

Benzodiazepines

Calculation of Pediatric Dosages

Coumadin

Diuretics

Enoxaparin

Inhaled Medications

Nebulizer Medications

Insulin

Opioid and Non-Opioid Analgesics

Oral Chemotherapy

Oral Hypoglycemics

Oral & Topics Nitrates

Rivaroxaban

Sedative/Hypnotics

Steroids

HOME HEALTH

1

2

3

4

Intake/Admissions

Case Manager

Case Load - Pts/Day(specify)

Supervise LVNs/HHAs

Medicare/Medicaid

Long/Short Term Disability

Private Insurance

Telephonic Assessments

Management of Complaints

APS Reports

OASIS

Diagnosis Coding

Document Plan of Care

Clinical Assessment Documentation

PROFESSIONAL KNOWLEDGE AND SKILLS

1

2

3

4

National Patient Safety Goals/Core Measures

Safety Assessment

Fall Assessment and Prevention

Patient/Family Teaching

Age Specific/Population Based Care

EMR

1

2

3

4

Allscripts

Cerner

EPIC

HomeCare Home Base

McKesson

Meditech

Other Computerized Documentation System

1

2

3

4

EMR Conversion

Yes

No

Certifications

1

2

3

4

BLS

ACLS

PALS

OASIS Training

Coding Training

IV Certification

Wound Care

Please read and agree to the statements below by marking the checkbox. You will not be able to submit until you have marked the checkbox. * I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize Hudson Staffing to release this Home Health Skills Checklist to the client facilities in relation to consideration of employment as a healthcare professional with those facilities.

Privacy Note: Hudson Staffing will record anonymous electronic information about your connection when you click on the submit button. This information is used for security purposes only. This information will include your IP Address (3.236.68.118) which will be used as a digital signature.