Medical / Surgical Skills Checklist

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Phone Number 
Email Address 

Please rate your experience / frequency (within the last year) using the following scale
(check the appropriate boxes below):

1 - No Experience / Theory Only
2 - Limited Experience / Need Review
3 - Frequent Experience / May Need Some Review
4 - Experienced / Perform Well 		1 - Observed Only / Never Done
2 - Rarely Done (<6 times/year)
3 - Occasionally Done (1 - 2 times/month)
4 - Frequently Done (daily or weekly)

Experience Frequency
AGE SPECIFIC COMPETENCY 1 2 3 4 1 2 3 4
Infants & Toddlers (0 - 3 years)
Young Children (4 - 6 years)
Older Children (7 - 12 years)
Adolescents (13 - 20 years)
Middle Adults (21 - 39 years)
Middle Adults (40 - 64 years)
Older Adults (65 - 79 years)
Adults (>80 years)
MEDICATION ADMINISTRATION 1 2 3 4 1 2 3 4
Pouring from Stock Medications
Narcotic Administration
IV Push Medications
IV Drip Medications
     Antibiotics
     Narcotics
     Chemotherapy
     Other
PHELBOTOMY/IV THERAPY 1 2 3 4 1 2 3 4
Draw Blood
     Arterial Line
     Central Line
Insert IVs
Mixing IVs
Regulating IVs
Discontinue Peripheral IV
IV Infusion Pumps
CVP Lines - Measurement of CVP
Central Line Dressing Changes
Blood/Blood Product Administration
Administration of
     Total Parenteral Nutrition (TPN)
     Peripheral Parenteral Nutrition (PPN)
Multi-Lumen Central Catheters
Port-A-Caths (Infusa-Ports)
Continuous Subcutaneous Infusion Pumps
Patient Controlled Analgesia (PCA)
Other
PATIENTS WITH NEUROLOGICAL PROBLEMS 1 2 3 4 1 2 3 4
Assessing Levels of Consciousness
Pupil Checks
Seizure Precautions
Aneurysm Precautions
Assisting with Lumbar Puncture
Administration of Anticonvulsant
Administration of IV Drip Steroids
Use of Hyper/Hypothermia Blanket
Care of Patient with
     Spinal Cord Injury - Acute
     Spinal Cord Injury - Long Term
     CVA - Stroke
     Neuromuscular Disease
     Alzheimer Disease
PATIENTS WITH WOUND/SKIN PROBLEMS 1 2 3 4 1 2 3 4
Dressing Changes
Care of Patient with
     Pressure Sores
     Leg Ulcers
     Burns
Use of Special Pressure Relief Devices
     Air Fluidized, Low Airloss Beds
     Pressure Relief Mattress/Seat Cushion
     Other
PATIENTS WITH ENDOCRINE PROBLEMS 1 2 3 4 1 2 3 4
Insulin Administration
     Single Type
     Mixed Insulins
     Insulin Infusion
Blood Glucose Monitoring
     Performing Fingersticks
     Use of Blood Glucose Meter Device
     Use of Visual Blood Glucose Strips
     Other
ADDITIONAL MEDICAL/SURGICAL SKILLS 1 2 3 4 1 2 3 4
Care of Patient with
     Hemovacs
     Jackson-Pratt Tubes
     Penrose Drains
     T-Tubes
Surgical Wound Irrigations & Dressings
Universal Precautions
Experience Frequency
PATIENTS WITH CARDIOVASCULAR PROBLEMS 1 2 3 4 1 2 3 4
Cardiac Monitors
Taking EKGs - 12 Lead
Basic & Life-Threatening Dysrhythmias
Recognizing Basic & Life-Threatening Dysrhythmias
Cardiopulmonary Resuscitation (CPR)
Defibrillation
Cardioversion
General
     Pulse Checks
     Use of Doppler
Use of Automatic BP Cuff (ie Dinamap)
Administration of Nitrates (Oral, Topical)
Administration of Antiarrhythmics (Oral)
Administration of Antihypertensives (Oral)
RESPIRATORY 1 2 3 4 1 2 3 4
O2 Cannulas/Masks
Nebulizer Set-up/Use
Incentive Spirometry
Chest PT
Pulse Oximetry
Suctioning
     Oral
     Tracheostomy Tube
Care of the Ventilator Patient
     Mouth care
     Suctioning - Endotracheal Tube
     Ambu Bags
     Weaning the Patient off the Ventilator
Bronchodilator Administration
     Oral
     IV
     Inhaler
Care of Patient with
     Tracheostomy Tube
     COPD
     Asthma Exacerbation
     Pneumonia
     Pre/Post Thoracic Surgery
     Chest Tubes
     Other
PATIENTS WITH RENAL/GU PROBLEMS 1 2 3 4 1 2 3 4
Insertion of Catheter
     Female
     Male
Bladder Irrigation
     Continuous
     Intermittent
Peritoneal Dialysis
     Manual
     Automatic Cycler Machine
Collection of Urine Specimens
Care of Patient on Hemodialysis
     A-V Fistula/Shunt Care
     Pre- & Post- Dialysis Care
Care of Patient with
     Urinary Diversion
     Suprapubic Catheter
     Nephrostomy Tube
PATIENTS WITH GASTROINTESTINAL PROBLEMS 1 2 3 4 1 2 3 4
Nasogastric Tubes (i.e. Salem Sump, Levine)
Nasointestinal Tubes (i.e. Cantor, Miller-Abbot)
Jejunostomy, Gastrostomy, Cecostomy Tubes
Inserting Nagostric Tubes
Tube Feedings via Flexible Tubes
     Nasogastric
     by Gravity Infusion
     by Feeding Pump
Collection of Stool Specimens
Bowel Preparation & Cleansing Procedures
Care of Patient with
     Ileostomy
     Colostomy
     Inflammatory Bowel Disease
PATIENTS WITH ORTHOPEDIC PROBLEMS 1 2 3 4 1 2 3 4
Cast Care
Circulation Checks
Traction - Skin
Traction - Skeletal
Range of Motion
Use of Assistive Devices
Care of Patient with
     Total Joint Replacement
     Rheumatic/Arthritic Disease
     Amputation
Applications of Splints of Extremities
Continuous Passive Motion Machine (CPM)

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the indivdual completing this form. I hereby authorize Texas Select Staffing to release this Skills Checklist to its client facilities for consideration of employment as a contractor at those facilities.

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