* Please note that fields marked with a * are required.
Date
* Applicant's Name: Last
Middle Initial
* First
To ArdorHealthSolutions Healthcare Professionals:
The following checklist is a profile used to assess your clinical proficiency and assist in matching your skills with available assignments. Your employment is not dependent upon responses given in this checklist. Please rate your ability as accurately as possible by checking the appropriate box.
The information I have given here is true and accurate to the best of my knowledge. In addition, I also authorize ArdorHealthSolutions to release this skills checklist to client institutions of ArdorHealthSolutions in relation to my employment with that institution.
* Signature (Please Type Full Name)
* Date
Please Mark Your Level of Experience 1 - No Experience: Theory / Observed Only 2 - Intermittent Experience: < 5 Times Per Year; Needs Review 3 - Moderate Experience: > 5 Times Per Year; May Need Minimal Resource 4 - Competent: Performs on Daily or Weekly Basis; Proficient
Basic Medical Knowledge
1
2
3
4
Knowledge of condition and medication used for the following disease categories.
Cardiovascular
CHF
Pacemakers
Endocrine
Diabetes
Thyroid
Gastrointestinal
Colostomy
Irritable Bowel Syndrome
Infectious Disease
AIDS/ARC
Hepatitis
Neurological
Alzheimers Disease
Neuromuscular Disorders
Seizure Disorder
Renal/Genitourinary
Foley Catheter
Dialysis Patients
Respiratory
Asthma
COPD
Respiratory Infections
Basic Knowledge of Procedure
Medication Administration
Universal Precautions
Seizure Precautions
Suicide Assessment and Precautions
Leadership Functions
Act as charge nurse when designated by Nurse Manager
Develop, interpret and implement policies and procedures for the hospital and unit
Guide non-licensed nursing staff in response to changes in the therapeutic milieu
Supervise nonprofessional staff and licensed psychiatric technician in providing quality nursing care
The Nursing Process
Accurately document patient care following unit policy
Administer medications
Assist doctor with physical exam and procedure
Direct treatment of patients as primary nurse responsibility
Establish therapeutic professional relationship with patients and families
Evaluate nursing care
Formulate nursing care plan based on nursing assessment using nursing diagnosis
In order to formulate the multi-disciplinary treatment plan, relate to other team disciplines in:
Assessment findings
Nursing care plan
Patient responses to interventions
Knowledgeable of neuroleptic medications:
Adverse Reactions
Dosage ranges
Purpose of
Side effects
Orient patient and family to hospital unit
Perform mental health nursing assessment upon admission of a new patient
Provide discharge planning
Complete discharge summaries for assigned patients
Revise nursing care
The Therapeutic Milieu
Apply restraints or impose seclusion when emergency situations arise
Assist psychiatric patients to regain impulse control
Encourage independent, healthy and mature behavior in patients
Initiate and manage suicide precautions with psychiatric patients following unit policy
Model conciseness and clarity in communication
Observe moods and interactions of patients, maintain awareness of tone of unit which may require therapeutic intervention
Provide a safe environment that protects patient's rights
Set limits on patient behaviors
Use empathic client centered communication to facilitate therapeutic interaction
Treatment Modalities
Conduct individual and group psychotherapy with appropriate supervision
Lead therapeutic community meetings
Meet with families of psychiatric patients to ensure open communication and compliance to treatment plan
Age of Patients Cared for
Infants and Toddlers (ages 0-3 years)
Young Children (ages 4-6 years)
Older Children (ages 7-12 years)
Adolescents (ages 13-20 years)
Young Adults (ages 21-39 years)
Middle Adults (ages 40-64 years)
Older Adults (ages 65+ years)
Certifications
Yes
No
Exp Date
ACLS
BCLS
CPR
Psychiatric & Mental Health Nurse
Other
Units Worked
Years
Hospital
Home Health
Locked Unit
Open Unit
Outpatient
Total Number of Years
List Courses for Critical Care
Course
Additional Skills Please list any additional experience or skills not previously listed.
