[checklist name= "Nurse Practitioner" mailto="credentialing@shaemarcus.com" templatedoc="1VWvi7mCr1jC9cZ6SKDfYKAtUZ762Q-dVVFv6zSSCGdg" templatedrive="1LG9WAg21_L3L-ZkZEChBzrYRhBOjpmcc" savedrive="15FFQjDXxe9nC9FkAAcuxbswGy1hq4sWm" sheetid="1xJkggLvktsyYL6zuIhdO-OURJhJTkWdDKunR11agspw"] [checklistHeading title="Nurse Practitioner"] Please rate your experience / frequency (within the last year) using the scale (check the appropriate boxes below) 0 = No theory and/or experience 1 = Limited experience/need supervision and/or support 2 = Experienced/minimal support needed to perform) 3 = Proficient/can perform independently 4 = Expert/very experienced in the field [/checklistHeading] [checklistInputGroup name="Recruiter Information"] [checklistInput type="text"]Recruiter TEEMA email[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Personal Information"] [checklistInput type="text"]Full Name[/checklistInput] [checklistInput type="email"]Your Email[/checklistInput] [checklistInput type="text"]Your phone number[/checklistInput] [checklistInput type="text"]Last 4 of Social Security Number[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Areas Worked"] [checklistInput type="scale"]Emergency[/checklistInput] [checklistInput type="scale"]Inpatient care[/checklistInput] [checklistInput type="scale"]Urgent care[/checklistInput] [checklistInput type="scale"]Private practice[/checklistInput] [checklistInput type="scale"]HMO[/checklistInput] [checklistInput type="scale"]MD office[/checklistInput] [checklistInput type="scale"]Schools[/checklistInput] [checklistInput type="scale"]Health department[/checklistInput] [checklistInput type="scale"]Ambulatory clinic[/checklistInput] [checklistInput type="scale"]Rural health clinic[/checklistInput] [checklistInput type="scale"]Psychiatric facility[/checklistInput] [checklistInput type="scale"]Correctional facility[/checklistInput] [checklistInput type="scale"]Mobile medical unit[/checklistInput] [checklistInput type="scale"]Corporate worksite[/checklistInput] [checklistInput type="scale"]Occupational health[/checklistInput] [checklistInput type="scale"]Nursing home/ Long term care facility[/checklistInput] [checklistInput type="scale"]Women’s health clinic[/checklistInput] [checklistInput type="scale"]Government health agency[/checklistInput] [checklistInput type="scale"]Acute care hospital[/checklistInput] [checklistInput type="scale"]Other (list)[/checklistInput] [checklistInput type="scale"]Patient population[/checklistInput] [checklistInput type="scale"]Neo-natal[/checklistInput] [checklistInput type="scale"]Pediatric[/checklistInput] [checklistInput type="scale"]Adolescent[/checklistInput] [checklistInput type="scale"]Adult[/checklistInput] [checklistInput type="scale"]Geriatric[/checklistInput] [checklistInput type="scale"]Migrant Workers[/checklistInput] [checklistInput type="scale"]Homeless[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Specialty"] [checklistInput type="scale"]ASHD (arteriosclerotic heart disease)[/checklistInput] [checklistInput type="scale"]Cardiac[/checklistInput] [checklistInput type="scale"]Dyslipidemia[/checklistInput] [checklistInput type="scale"]Gastroenterology[/checklistInput] [checklistInput type="scale"]Osteomyelitis[/checklistInput] [checklistInput type="scale"]PVD (peripheral vascular disease)[/checklistInput] [checklistInput type="scale"]HTN (hypertension)[/checklistInput] [checklistInput type="scale"]Peripheral neuropathy[/checklistInput] [checklistInput type="scale"]Diabetes[/checklistInput] [checklistInput type="scale"]Orthopedic[/checklistInput] [checklistInput type="scale"]Emergency department[/checklistInput] [checklistInput type="scale"]Other (list)[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Experience with"] [checklistInput type="scale"]Oxygen administration[/checklistInput] [checklistInput type="scale"]Liquid oxygen[/checklistInput] [checklistInput type="scale"]Naso-gastric tubes[/checklistInput] [checklistInput type="scale"]IPPB machine use (C-PAP)[/checklistInput] [checklistInput type="scale"]Diabetes[/checklistInput] [checklistInput type="scale"]Catheter care[/checklistInput] [checklistInput type="scale"]Contractures[/checklistInput] [checklistInput type="scale"]Incontinence care-bowel/bladder[/checklistInput] [checklistInput type="scale"]Dermal ulcers[/checklistInput] [checklistInput type="scale"]Enemas/ Suppositories/ Fecal impaction[/checklistInput] [checklistInput type="scale"]Injections[/checklistInput] [checklistInput type="scale"]Staph infections[/checklistInput] [checklistInput type="scale"]Tracheotomies[/checklistInput] [checklistInput type="scale"]Wound care[/checklistInput] [checklistInput type="scale"]Bedridden residents[/checklistInput] [checklistInput type="scale"]Pap smears[/checklistInput] [checklistInput type="scale"]Visual acuity[/checklistInput] [checklistInput type="scale"]Audiometry[/checklistInput] [checklistInput type="scale"]Tym-panometry[/checklistInput] [checklistInput type="scale"]Splinting of extremities[/checklistInput] [checklistInput type="scale"]Interpreting 12 lead EKG’s[/checklistInput] [checklistInput type="scale"]Interpret ABG (blood gases)[/checklistInput] [checklistInput type="scale"]Local infiltration[/checklistInput] [checklistInput type="scale"]Single layer wound closure[/checklistInput] [checklistInput type="scale"]Flourescein staining of eyes[/checklistInput] [checklistInput type="scale"]Radiographic interpretation (initial)[/checklistInput] [checklistInput type="scale"]Incision and drainage[/checklistInput] [checklistInput type="scale"]Excisions[/checklistInput] [checklistInput type="scale"]Intubations[/checklistInput] [checklistInput type="scale"]Comprehensive physical assessment[/checklistInput] [checklistInput type="scale"]Acute disease condition[/checklistInput] [checklistInput type="scale"]Chronic disease conditions[/checklistInput] [checklistInput type="scale"]Family history[/checklistInput] [checklistInput type="scale"]Differential diagnosis[/checklistInput] [checklistInput type="scale"]Order, may perform, and interpret screening and diagnostic tests[/checklistInput] [checklistInput type="scale"]Informed consent[/checklistInput] [checklistInput type="scale"]Explanation to patient/ family[/checklistInput] [checklistInput type="scale"]Documentation[/checklistInput] [checklistInput type="scale"]Venipuncture[/checklistInput] [checklistInput type="scale"]Urine collection[/checklistInput] [checklistInput type="scale"]Sputum collection[/checklistInput] [checklistInput type="scale"]Pregnancy test kits[/checklistInput] [checklistInput type="scale"]Hemoglobinmeter[/checklistInput] [checklistInput type="scale"]Ultrasounds[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Collaboration"] [checklistInput type="scale"]Family, support system, community resources[/checklistInput] [checklistInput type="scale"]Consulting with Physicians[/checklistInput] [checklistInput type="scale"]Consulting with Pharmacists[/checklistInput] [checklistInput type="scale"]Consulting with Speech Therapist[/checklistInput] [checklistInput type="scale"]Consulting with Dietician and Diet Aide[/checklistInput] [checklistInput type="scale"]Consulting with Occupational Therapist[/checklistInput] [checklistInput type="scale"]Referral to Pastoral services[/checklistInput] [checklistInput type="scale"]Other (list)[/checklistInput] [checklistInput type="scale"]Drug therapy[/checklistInput] [checklistInput type="scale"]Prescription[/checklistInput] [checklistInput type="scale"]Over the counter (OTC)[/checklistInput] [checklistInput type="scale"]Knowledge of pharmacology[/checklistInput] [checklistInput type="scale"]Knowledge of pharmacokinetics[/checklistInput] [checklistInput type="scale"]Knowledge of drug interactions[/checklistInput] [checklistInput type="scale"]Knowledge of side effects[/checklistInput] [checklistInput type="scale"]Knowledge of potential adverse reactions[/checklistInput] [checklistInput type="scale"]Allergic reactions[/checklistInput] [checklistInput type="scale"]Anaphylaxis reaction[/checklistInput] [checklistInput type="scale"]Dispensing medications[/checklistInput] [checklistInput type="scale"]Monitoring drug therapy[/checklistInput] [checklistInput type="scale"]Management of controlled substances[/checklistInput] [checklistInput type="scale"](DEA)[/checklistInput] [checklistInput type="scale"]Non-pharmacologic interventions[/checklistInput] [checklistInput type="scale"]Medical nutrition therapy[/checklistInput] [checklistInput type="scale"]Exercise[/checklistInput] [checklistInput type="scale"]Cessation of substance abuse (alcohol, tobacco)[/checklistInput] [checklistInput type="scale"]Mental health issues (stress management, depression)[/checklistInput] [checklistInput type="scale"]Obesity management[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Miscellaneous"] [checklistInput type="scale"]Public health and health promotion[/checklistInput] [checklistInput type="scale"]Research[/checklistInput] [checklistInput type="scale"]Quality assurance[/checklistInput] [checklistInput type="scale"]Leadership and teaching skills[/checklistInput] [checklistInput type="scale"]Legal and ethical issues[/checklistInput] [checklistInput type="scale"]Confidentiality[/checklistInput] [checklistInput type="scale"]Cultural awareness[/checklistInput] [checklistInput type="scale"]Self evaluation to improve patient care[/checklistInput] [checklistInput type="scale"]Continuing education[/checklistInput] [checklistInput type="scale"]Working within scope of practice[/checklistInput] [checklistInput type="scale"]Discharge planning/ collaboration[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Programs"] [checklistInput type="scale"]OSHA (Occupational, Safety and Health Administration)[/checklistInput] [checklistInput type="scale"]CLIA waiver (Clinical Laboratory Improvement Amendments)[/checklistInput] [checklistInput type="scale"]JCAHO (Joint commission on Accreditation of Healthcare Organizations)[/checklistInput] [checklistInput type="scale"]HEDIS (Health Plan Employer Data and Information Set)[/checklistInput] [checklistInput type="scale"]DQIP (Diabetes Quality Improvement Program)[/checklistInput] [checklistInput type="scale"]HIPAA (Health Insurance Portability and Accountability Act)[/checklistInput] [checklistInput type="text"]Other (list)[/checklistInput] [/checklistInputGroup] [checklistFooter] [/checklistFooter] [/checklist]