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Medical Surgical Skills Checklist
*required fields

My responses in this checklist represent a true reflection of my experience and comfort level.

 

Please self-rate your comfort level in performing tasks in connection with the below checklist.  Rate your level of comfort for each line item by following the below ranking system.  Simply fill in the appropriate option immediately following the rating number.

 

Typed Name (typing your name below serves as an electronic signature) *      Date*

                                                         

 

Phone*

           

 

My Recruiting Professional at Health Source Group is: 

 

Certifications: (Check all that apply)

     BLS/BCLS/CPR:
     ACLS:
     CHEMO:
     ONC:

Level of Comfort/Experience

N/A=Non-applicable

1=Inexperienced in this area

2=Limited comfort/experience in this area

3=Comfortable/experienced in this area

4=Very comfortable/highly experienced in this area
 

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Cardiovascular

Basic 12 lead EKG interpretation

N/A  

1

2

3

4

Use of Cardiac Monitor

N/A  

1

2

3

4

Assessment of heart sounds (normal vs. abnormal)

N/A  

1

2

3

4

Cardiac arrest/CPR

N/A  

1

2

3

4

Heparin drip (Precautions and maintenance)

N/A  

1

2

3

4

Peripheral Pulses

N/A  

1

2

3

4

Use and administration of

N/A  

1

2

3

4

Anticoagulants

N/A  

1

2

3

4

Antihypertensives

N/A  

1

2

3

4

Digoxin

N/A  

1

2

3

4

Nitroglycerine

N/A  

1

2

3

4

Permanent pacemaker

N/A  

1

2

3

4

Cardiac surgery

N/A  

1

2

3

4

Post acute MI

N/A  

1

2

3

4

Congestive heart failure (CHF)

N/A  

1

2

3

4

Femoral popliteal bypass/Vascular Procedures

N/A  

1

2

3

4

Abdominal aortic aneurysm

N/A  

1

2

3

4

Carotid endarterectomy

N/A  

1

2

3

4

Thrombophlebitis

N/A  

1

2

3

4

 

Pulmonary

Assessment of breath sounds

N/A  

1

2

3

4

Chest Physiotherapy

N/A  

1

2

3

4

Oral suctioning

N/A  

1

2

3

4

Nasotracheal suctioning

N/A  

1

2

3

4

Chest tube (care and maintenance)

N/A  

1

2

3

4

Oxygen Therapy Administration:

N/A  

1

2

3

4

Bag and Mask

N/A  

1

2

3

4

Nasal cannula

N/A  

1

2

3

4

Facemask

N/A  

1

2

3

4

Albuterol (Ventolin)

N/A  

1

2

3

4

Corticosteroids

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

Mechanical ventilator

N/A  

1

2

3

4

COPD

N/A  

1

2

3

4

Emphysema

N/A  

1

2

3

4

Pneumonia

N/A  

1

2

3

4

Pulmonary edema

N/A  

1

2

3

4

 

Neurology

Assessment of neurological status

N/A  

1

2

3

4

Use of Glasgow Coma Scale

N/A  

1

2

3

4

Halo traction