Medical/Surgical Competency Self Assessment Experience Directions
Please circle a value for each question to provide us and the interested facilities with an assessment of
your clinical experience. These values confirm your
strengths within your specialty and assist the facility in
3 Intermittent Experience (May Require Assistance)
the selection process of the healthcare professional.
4 Experienced (Performs without Assistance)
5 Very Experienced (Able to Teach/Supervise)
________________________________________________________________________________________________________ Print Name Last 4 Digits of SS# General Skills Experience Advanced directives Patient/family teaching Restrictive devices (restraints) Lift/transfer devices Specialty beds End of life care/palliative care Automated Medication Dispensing System, Pyxis, Omnicell, or other Bar coding for medication administration National Patient Safety Goals Accurate patient identification Effective communication Interpretation & communication of lab values Medication administration Labeling Anticoagulation therapy Reconciliation Monitoring conscious sedation Pain assessment & management Use of PCA (IV, intrathecal, epidural) Infection control Universal precautions Isolation Minimize risk for falls Prevention of pressure ulcers Wound care Wound vacs Awareness of HCAHPS Cardiac Monitoring & Emergency Care Obtains 12 lead EKG Interpretation of rhythm strips Treatment of dysrythmias Use of rapid response teams Experience
3 Intermittent Experience (May Require Assistance)
Initials ___________
4 Experienced (Performs without Assistance)
5 Very Experienced (Able to Teach/Supervise)
General Skills - cont. Experience Cardiac arrest/CPR O2 therapy & delivery Pulse oximetry Use of doppler IV Therapy Starting & maintaining peripheral IVs Blood draw: venous Central line care Blood draw: central line Care & management of ports Care & management of PICC/Groshong/Hickman TPN & lipids Administration of blood/blood products Administration of chemotherapy Monitoring chemotherapy (does not initiate) Other Diabetes mellitus Blood Glucose Monitoring (BGM) Insulin administration Experience Assessment of heart sounds Pacemakers - permanent Care of Patient with: Aneurysm Angioplasty (pre/post) Carotid endarterectomy Pre/post cardiac cath Pre/post cardiac surgery Use & Administration of the Following: Antiarrhythmic Antihypertensives Beta blockers Diuretics Nitrates Fibrinolytics/IIb IIIa inhibitors Experience
3 Intermittent Experience (May Require Assistance)
Initials ___________
4 Experienced (Performs without Assistance)
5 Very Experienced (Able to Teach/Supervise)
Respiratory Experience Assessment of breath sounds Chest tubes (Emerson/Pleuravac) Interpretation of ABG Incentive spirometer Mechanical ventilation Oral suctioning Nasotracheal suctioning Tracheostomy care Care of Patient with: COPD Pre/post thoracic surgery Thyroidectomy Pulmonary embolism Pulmonary edema Pneumothorax Pneumonia Inhalation injuries Tuberculosis Emphysema Use & Administration of the Following: Bronchodilators Steroids Expectorants Gynecology Experience Endometriosis Gyn exam/pap Self breast exam Tubal ligation Ectopic pregnancy Mastectomy/lumpectomy Hysterectomy (vaginal or TAHBSO) Repair of cystocele/rectocele Pelvic inflammatory disease Abnormal uterine bleeding Experience
3 Intermittent Experience (May Require Assistance)
Initials ___________
4 Experienced (Performs without Assistance)
5 Very Experienced (Able to Teach/Supervise)
Neurology Experience Glasgow coma scale Seizure precautions Assist with lumbar puncture Halo traction Care of Patient with: CVA Overdose Spinal cord injury/trauma TBI (Traumatic Brain Injury) Pre/post neuro surgery Cranial hemorrhage Delirium tremors Meningitis Neuromuscular diseases Use & Administration of the Following: Antiepileptics Corticosteroids Steroids Gastrointestinal Experience NG tube insertion Management of small bore feeding tubes (Dobhoff, Keofeed) Jejunostomy tube Care of Patient with: Pancreatitis Hepatitis G.I. bleed Esophageal bleeding Bowel obstruction Bowel resection Gastric bypass Gastric banding Whipple procedure Transplants (specify) Colostomy/ileostomy Experience
3 Intermittent Experience (May Require Assistance)
Initials ___________
4 Experienced (Performs without Assistance)
5 Very Experienced (Able to Teach/Supervise)
Gastrointestinal - cont. Experience Paralytic ileus Use & Administration of the Following: Anticholinergics (antispas, bentyl or robinul) Cathartics Genitourinary/Renal Experience Catheter insertion GU irrigations Nephrostomy tube Suprapubic tube Care of Patient with: Hemodialysis T.U.R.P. Shunts and fistulas Nephrectomy Peritoneal dialysis Renal transplant Chronic/acute renal failure Orthopedic Experience Total joint replacement Arthroscopic surgery Bucks extension Fasciotomy Fractures Spika cast/body cast TENS unit Cast care & removal Amputation Skeletal traction Ortho trauma Cervical fusion Laminectomy Experience
3 Intermittent Experience (May Require Assistance)
Initials ___________
4 Experienced (Performs without Assistance)
5 Very Experienced (Able to Teach/Supervise)
Experience Care of patient with sepsis Oncology Chemotherapy Radiation therapy Radiation implants Inpatient hospice Suicide precautions Burn patients Additional Skills Leadership skills (team leader or charge nurse) Age Specific Competencies Experience Newborn/neonate (birth-30 days) Infant (31 days-1 year) Toddler (ages 2-3 years) Preschool (ages 4-5 years) School age (ages 6-12 years) Adolescent (ages 13-21 years) Young adult (ages 22-39 years) Adult (ages 40-64 years) Older adult (ages 65-79 years) Elderly (ages 80+ years) Please list any Additional Skills: Additional training: 1. Additional equipment: 1. Fax to: 1-888-298-3146 The information on this and all preceding pages is true and correct. ___________________________________________________________________________________________________ Signature
http://mutagens.co.in PROTHROMBIN TIME & INTERNATIONAL NORMALIZED RATIO IN PEDIATRIC LIVER DISEASE 1Senior Resident, Department Of Pediatrics , VSS Medical College & Hospital, Burla, Sambalpur, Odisha 2Associate Professor, Department Of Pediatrics , VSS Medical College & Hospital, Burla, Sambalpur, Odisha 3Senior Resident, Department Of Pediatrics , VSS Medical College