Medical/Surgical

Requested by *

Recruiter Email ID *

First Name *

Last Name *

Phone Number *

Today's Date *

Your Email Address *

WORK SETTING EXPERIENCE

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Inpatient Acute Care Facility *

Trauma Center *

Academic/Teaching Facility *

Outpatient Care Facility *

Long term care/Skilled Nursing *

Clinic/Ambulatory *

Home Health Setting *

GENERAL SKILLS EXPERIENCE

Rank each of the following sections on a scale of 1 to 5:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Advanced directives *

Awareness of HCAHPS *

Patient/family teaching *

Computerized Documentation *

Restraints *

Lift/Transfer Devices *

Specialty beds *

End of Life/Palliative Care *

Automated Medication Dispensing Systems (Pyxis, Omnicell) *

Bar coding for medication administration *

National Patient Safety Goals *

Accurate Patient Identification *

Interpretation and communication of lab values *

Medication Administration 5 rights *

Labeling (specimens, labs) *

Medication Reconciliation *

Pain Assessment and management *

Infection Control *

Universal Precautions *

Isolation *

Minimize risk for falls *

CARDIAC MONITORING & EMERGENCY CARE

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Rapid Response Teams *

Cardiac Arrest/ CPR *

Oxygen therapy and delivery *

Pulse oximetry *

Use of Doppler/pulse checks *

Automatic/manual Blood Pressure checks *

IV THERAPY

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Starting and maintaining peripheral Iv’s *

Blood Draw: venous *

Multi Lumen Central line care and dressing changes *

Blood Draw Central line *

IV Push *

Care & Management of Port a catheter *

Care & Management of PICC/ Groshong/Hickman *

TPN and Lipids *

Administration of blood/blood products *

Administration of Chemotherapy *

Monitoring Chemotherapy (does not initiate) *

IV drip calculations *

IV fluids *

Management of IV Infusion Pumps (Alaris, Baxter) *

Management of elastomeric infusion *

Management of intrathecal pumps *

CARDIAC EXPERIENCE & CARE OF A PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Auscultation of Irregular of Heart Sounds *

Angina *

Anticoagulation therapy *

arrhythmias *

Abdominal Aortic Aneurysm *

Carotid Endarterectomy *

Congestive heart Failure *

Cardiomyopathy *

Coagulation *

Endocarditis *

Femoral Popliteal Bypass *

Hypertension *

Pulse oximetry *

Pericarditis *

Peripheral Edema *

Pulse/Circulation checks *

MEDICATION ADMINISTRATION:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Antihypertensive medications (Beta Blockers, Antiarrhythmics, Ace Inhibitors, Calcium Channel Blockers) *

Inotropic: (digoxin) *

Antiarrhythmics (Pacerone, Rythmol) *

Beta Blockers (Sotalol, metroprolol) *

Ace Inhibitors (Catopril, Ramipril, Vasotec) *

Antianginals (isordil/nitrates) *

Antilipemic: statins *

Anticoagulation medications (heparin, Coumadin, *

Diuretics *

PULMONARY EXPERIENCE & CARE OF A PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Assessment of abnormal breath sounds *

Aspiration *

Asthma *

Emphysema *

Airway management/suctioning (Oral, trach) *

ABG’s recognition and treatment of abnormal values *

Acute Pneumonia *

Pneumothorax *

Chest Tube care and management *

Incentive spirometer *

COPD *

Lobectomy *

Pre/Post Thoracic Surgery *

Lung transplant *

Thoracentesis *

Oxygen administration *

Ambu bag *

Nasal Canula *

Nebulizer treatments *

Trach collar *

Non-rebreather *

TB *

Venti mask *

Tracheostomy Care *

Bronchoscopy *

MEDICATION ADMINISTRATION:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Expectorants and anti-tussins *

Antihistamines *

Bronchodilators *

inhalers *

Steroids *

NEUROLOGY EXPERIENCE & CARE OF A PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Glasgow Coma Scale *

Level of Consciousness *

Comprehensive neuro assessment *

CVA/ TIA *

Intercranial Hemorrhage & hematoma *

Reflex motor deficits *

Visual communication deficit *

CNS infection *

Meningitis *

Encephalitis *

Alzheimer’s Disease *

Delirium Tremens *

Overdose *

Neuromuscular disease *

Multiple Sclerosis *

Metastatic Tumor *

Tumor resection *

Pre/Post Neuro Surgery *

Laminectomy *

Assist Lumbar Puncture *

Halo Traction *

Seizure Disorder *

Spinal Cord Injury *

Traumatic Brain Injury *

MEDICATION ADMINISTRATION USE & ADMINISTRATION OF THE FOLLOWING:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Anticonvulsants (Dilantin/ Phenobarbital) *

Antidepressants *

Antiparkinson’s (Cogentin/Levodopa/Sinemet) *

Corticosteroids *

GASTROINTESTINAL EXPERIENCE & CARE OF A PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Assessment of Bowel Sounds *

Nutritional Status *

Interpretation of labs and electrolyte imbalance *

Bowel Obstruction *

EGD *

Insertion and management of NG tube *

Bowel Prep/Colonoscopy *

Nausea/vomiting *

Constipation/impaction *

ERPC *

diarrhea *

Insertion and management of small-bore feeding tubes (Dubhoff, Keofeed) *

Management and care of PEG tub/feed *

Management and care of gastrostomy tube/feed *

Management and care of jejunostomy tube/feed *

Gravity/bolus feedings *

Kangaroo pump *

Management and care of ostomy *

Abdominal wounds *

Pre/Post abdominal surgery *

Paralytic Ileus *

Management of post-surgical drains *

Gastric Bypass *

Peritonitis *

GI bleed (upper/lower) *

Hepatitis *

Inflammatory Bowel Disease *

Liver Failure *

Paracentesis *

Pancreatic Cancer *

MEDICATION ADMINISTRATION USE & ADMINISTRATION OF THE FOLLOWING:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Antiemetics *

Antispasmodics *

Anticholinergics *

Laxatives *

GENITOURINARY/RENAL EXPERIENCE & CARE OF A PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Insertion and maintenance of urethral catheter *

Care of Nephrostomy tube *

Care of Suprapubic catheter *

GU irrigation *

Kidney Failure (acute/Chronic) *

Measurement of Intake and Output Monitoring *

Urine Retention *

CARE OF PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Pyelonephritis/UTI *

BPH *

TURP *

Prostate Cancer *

Nephrectomy *

Ileoconduit *

Renal Surgery *

Hemodialysis *

Peritoneal Dialysis *

Shunts/Fistulas *

Obstructions *

Renal Trauma *

Testicular Torsion *

ORTHOPEDIC EXPERIENCE & CARE OF A PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Assess Range of Motion *

Assessment of color, warmth, movement, sensation *

Amputation *

Cast Care *

Fractures *

Splints *

Traction *

Trauma *

Strains/Sprain *

immobilization *

METABOLIC/ENDOCRINE EXPERIENCE & CARE OF A PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Diabetes *

Blood Glucose Monitoring *

Cushing’s Syndrome *

Thyroid Disease *

Post Thyroidectomy Care *

SKIN/INTEGUMENTARY & CARE OF A PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Skin assessment *

Skin Breakdown monitoring *

Staged Pressure Ulcers *

Stasis Ulcers *

Sterile dressing changes *

Wound Vac maintenance and dressing changes *

AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

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) *