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 Pediatric 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

WORK SETTINGS

1

2

3

4

Pediatric MedSurg

Pediatric Step Down/Telemetry

Pediatric Oncology

Pediatric Ortho

Pediatric Neuro

CARDIOVASCULAR

1

2

3

4

Congenital Heart Disease/Repair

Pre Cardiac Surgery

Post Cardiac Surgery

Heart Sounds

PULMONARY

1

2

3

4

Reactive Airway Disease

RSV

Tuberculosis

Esophageal Atresia

Epiglottitis

Tonsillitis

Laryngotracheobronchitis (Croup)

ENT Surgery

Oxygen Delivery Systems

Tracheostomy Management

Oral Suctioning

Deep Suctioning

Management of Chest Tubes

Apnea Monitor

Home Ventilator Therapy

NEUROLOGIC/ORTHOPEDIC

1

2

3

4

Brain Injury

Spinal Cord Injury

Seizure Disorders

Meningitis

Neuromuscular Disease

Extremity Fracture/Cast

Post Vertebral Surgery

Traction - General

Traction - Halo

Pin Care

VP Shunts/Internal/External

GASTROINTESTINAL

1

2

3

4

Cleft Lip/Palate

Inflammatory Bowel Disease

Colostomy/Ileostomy

Surgical Drains

Failure to Thrive

Feeding Intolerance

Gastroenteritis/Dehydration

Bowel Obstruction

Short Gut Syndrome

Breastfeeding Support/Handling of Breast Milk

RENAL/GENITOURINARY

1

2

3

4

Circumcision

Testicular Torsion

Glomerulonephritis

Renal Failure

Renal Transplant

Urinary Retention

Bladder Scan

Insertion/Management of Bladder Catheters

Management of Suprapubic Catheters

ENDOCRINE/METABOLIC

1

2

3

4

Diabetes - Hypo/Hyperglycemia

Diabetic Ketoacidosis

IV Insulin Pumps

Indwelling Insulin Pumps

Hyperbilirubinemia

Bili Bed

ONCOLOGY

1

2

3

4

Chemotherapy Administration

Hodgkin's Disease

Hemophilia

Sickle Cell Anemia

Leukemia

Solid Tumors

Bone Marrow Transplant

INFECTIOUS DISEASE

1

2

3

4

Childhood Communicable Diseases

Hepatitis

HIV

Kawasaki Disease

MEDICATIONS

1

2

3

4

Pediatric Dosage Calculations

Anti-Hypertensives

Anticoagulants

Anti-Seizure Medications

Benzodiazepines

Digoxin

Diurectics

Emergency Medications

Inhaled Medications

Insulin

Narcotics/Opioid Analgesics (IV/Oral/Injection)

Non-Opioid Analgesics (IV/Oral/Injection)

Procedural Sedation - Recovery

Reversal Agents

Steroids (IV/Oral/Inhaled)

Automated Medication Dispensing (i.e. Pyxis, Omnicell)

IV THERAPY

1

2

3

4

Starting IVs

Central Line Blood Draw

Central Line/Implanted Line Care

TPN/Lipids

Blood Product Administration

Administration of Chemotherapy

CARDIAC MONITORING & EMERG. RESPONSE

1

2

3

4

Pediatric Early Warning Score (PEWS)/Rapid Response Team

Dysrhythmia Interpretation

Dysrhythmia Management

PROFESSIONAL KNOWLEDGE AND SKILLS

1

2

3

4

National Patient Safety Goals/Core Measures

Recognize/Report Signs of Abuse

Fall Risk Assessment/Prevention

Pressure Ulcer Risk Assessment/Prevention

Restraints/Use of Least Restrictive Device

Normal Growth and Development

Age Specific/Population Based Care

Patient Family Teaching

Isolation Precautions

Infection Prevention

Reporting Communicable Diseases

Pain Assessment & Management

Charge Experience

Interpretation and Communication of Lab Values

EMR

1

2

3

4

EPIC

Cerner

Eclipsys

McKesson

Meditech

Other Computerized System

Computerized Physician Order Entry

Bar Coding for Medication Administration

EMR Conversion

Yes

No

Certifications

1

2

3

4

BLS

PALS

CPHON

Chemo Certification

PICC Certification

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 Pediatric 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 (3.237.16.210) which will be used as a digital signature.