Nurse Practitioner

    Instruction

    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

Recruiter Information

Recruiter TEEMA email

Personal Information

Full Name

Email

Phone number

Last 4 of Social Security Number

Date

Areas Worked

Emergency

Inpatient care

Urgent care

Private practice

HMO

MD office

Schools

Health department

Ambulatory clinic

Rural health clinic

Psychiatric facility

Correctional facility

Mobile medical unit

Corporate worksite

Occupational health

Nursing home/ Long term care facility

Women’s health clinic

Government health agency

Acute care hospital

Other (list)

Patient population

Neo-natal

Pediatric

Adolescent

Adult

Geriatric

Migrant Workers

Homeless

Specialty

ASHD (arteriosclerotic heart disease)

Cardiac

Dyslipidemia

Gastroenterology

Osteomyelitis

PVD (peripheral vascular disease)

HTN (hypertension)

Peripheral neuropathy

Diabetes

Orthopedic

Emergency department

Other (list)

Experience with

Oxygen administration

Liquid oxygen

Naso-gastric tubes

IPPB machine use (C-PAP)

Diabetes

Catheter care

Contractures

Incontinence care-bowel/bladder

Dermal ulcers

Enemas/ Suppositories/ Fecal impaction

Injections

Staph infections

Tracheotomies

Wound care

Bedridden residents

Pap smears

Visual acuity

Audiometry

Tym-panometry

Splinting of extremities

Interpreting 12 lead EKG’s

Interpret ABG (blood gases)

Local infiltration

Single layer wound closure

Flourescein staining of eyes

Radiographic interpretation (initial)

Incision and drainage

Excisions

Intubations

Comprehensive physical assessment

Acute disease condition

Chronic disease conditions

Family history

Differential diagnosis

Order, may perform, and interpret screening and diagnostic tests

Informed consent

Explanation to patient/ family

Documentation

Venipuncture

Urine collection

Sputum collection

Pregnancy test kits

Hemoglobinmeter

Ultrasounds

Collaboration

Family, support system, community resources

Consulting with Physicians

Consulting with Pharmacists

Consulting with Speech Therapist

Consulting with Dietician and Diet Aide

Consulting with Occupational Therapist

Referral to Pastoral services

Other (list)

Drug therapy

Prescription

Over the counter (OTC)

Knowledge of pharmacology

Knowledge of pharmacokinetics

Knowledge of drug interactions

Knowledge of side effects

Knowledge of potential adverse reactions

Allergic reactions

Anaphylaxis reaction

Dispensing medications

Monitoring drug therapy

Management of controlled substances

(DEA)

Non-pharmacologic interventions

Medical nutrition therapy

Exercise

Cessation of substance abuse (alcohol, tobacco)

Mental health issues (stress management, depression)

Obesity management

Miscellaneous

Public health and health promotion

Research

Quality assurance

Leadership and teaching skills

Legal and ethical issues

Confidentiality

Cultural awareness

Self evaluation to improve patient care

Continuing education

Working within scope of practice

Discharge planning/ collaboration

Programs

OSHA (Occupational, Safety and Health Administration)

CLIA waiver (Clinical Laboratory Improvement Amendments)

JCAHO (Joint commission on Accreditation of Healthcare Organizations)

HEDIS (Health Plan Employer Data and Information Set)

DQIP (Diabetes Quality Improvement Program)

HIPAA (Health Insurance Portability and Accountability Act)

Other (list)

Please read and agree to the statements below by marking the checkbox.

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Company to release this Skills Checklist to the Client facilities in relation to consideration of employment as a Healthcare Professional with those facilities.

Thank you for your submission, we will look over your message and get back to you ASAP.