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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.

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