Medical / Surgical Skills Checklist

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

Proficiency:

Age Specific Competency

Medication Administration

Phlebotomy / IV Therapy

Patients with Neurological Problems

Patients with Wound / Skin Problems

Patients with Endocrine Problems

Additional Medical / Surgical Skills

Patients with Cardiovascular Problems

Respiratory

Patients with Renal / GU Problems

Patients with Gastrointestinal Problems

Patients with Orthopedic Problems