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 Medical / Surgical 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

Cardiac

1

2

3

4

Angina

Post Acute MI

Congestive Heart Failure

Post Cardiac Cath

Post Cardiac Surgery

Aneurysm

Carotid Endarterectomy

Post Vascular Surgery

Post Cardiac Transplant

PULMONARY

1

2

3

4

Pneumonia

COPD

Tuberculosis

Pulmonary Embolism

Tracheostomy Management

CPAP/BiPAP

Interpretation of Arterial Blood Gases

Post Lung Transplant

Neurological & Psychiatric

1

2

3

4

Stroke Scale Assessment

Traumatic Brain Injury

CVA

Post Craniotomy

Seizure Disorders

Spinal Cord Injuries

Mood Disorders

Substance Withdrawal

ORTHOPEDICS

1

2

3

4

Circulation/Skin Checks

Continuous Passive Motion Devices

Ambulation Assistive Devices

Prosthetics

Cast Care

Pin Care

Traction

Total Joint Replacement

Amputation

GASTROINTESTINAL

1

2

3

4

Bariatrics

Feeding Tubes

GI Bleeding

Bowel Obstruction

GI Surgery

Liver Disease

Pancreatitis

Post Liver Transplant

Post Pancreas Transplant

RENAL/GENITOURINARY

1

2

3

4

Arteriovenous Fistula/Shunt

3 Way Catheter & Bladder Irrigation

Suprapubic Catheter

Renal Failure

Peritoneal Dialysis

GU Surgery

Nephrostomy Tubes

Renal Transplant

Management Pre/Post Hemodialysis

Gyn Surgery

Endocrine Metabolic

1

2

3

4

Diabetes Type I

Diabetes Type II

Blood Glucose Monitoring

IV Insulin Protocols

Management of Hypoglycemia

Indwelling Insulin Pumps

Pituitary Disorders

ONCOLOGY

1

2

3

4

Chemotherapy Administration

Radiation Therapy

Medical Oncology

Surgical Oncology

Radiation Implants

Bone Marrow Transplant

MEDICATIONS

1

2

3

4

Antiarrhythmics

Anticoagulants (IV, oral, & injection)

Anti-Depressants

Anti-Hypertensives

Anti-Psychotics

Benzodiazepines

Emergency Medications

Epidural Analgesia

Inhaled Medications

Insulin

Narcotics/Opioid Analgesics (IV, oral, & injection)

Nitrates (Oral & Topical)

Non-Opioid Analgesics (IV, Oral, & Injection)

Oral Hypoglycemics

Patient Controlled Analgesia

Procedural Sedation Administration

Reversal Agents

Steroids (IV, Oral, Inhaled)

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

IV THERAPY

1

2

3

4

Starting IVs

Central Line Blood Draws

Central Line/Implanted Line Care

TPN & Lipids

Blood Product Administration

Monitoring of Chemotherapy

CARDIAC MONITORING & EMERG. RESPONSE

1

2

3

4

Placement of Telemetry Leads

Rhythm Interpretation

Dysrhythmia Management

Obtain 12 Lead EKG

Use of Rapid Response Teams

PROFESSIONAL KNOWLEDGE AND SKILLS

1

2

3

4

National Patient Safety Goals/Core Measures

Fall Risk Assessment/Prevention

Pressure Ulcer Risk Assessment/Prevention

Restraints/Use of Least Restrictive Device

Patient/Family Teaching

Age Specific/Population-Based Care

Isolation Precautions

Infection Prevention

Pain Assessment & Management

Charge Experience

Interpretation and Communication of Lab Values

Wound Care /Wound Vac

Specialty Beds

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

BLS

ACLS

Telemetry Certificate

ONS Chemo/Biotherapy Certification

Other Chemo 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 Medical / Surgical 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 (34.237.51.159) which will be used as a digital signature.