Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
| Areas Worked | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Emergency |
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| Urgent Care |
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| Private Practice |
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| HMO |
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| MD Office |
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| Schools |
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| Health Department |
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| Ambulatory Clinic |
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| Rural Health Clinic |
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| Psychiatric Facility |
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| Correctional Facility |
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| Mobile Medical Unit |
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| Corporate Worksite |
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| Occupational Health |
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| Rehabilitation |
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| Nursing Home/ Long-term Care Facility |
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| Women's Health Clinic |
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| Government Health Agency |
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| Hospice/Palliative Care |
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| Experience With | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Diabetes |
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| Contractures |
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| Bedridden residents |
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| Splinting of extremities |
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| Local infiltration |
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| Comprehensive physical assessment |
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| Acute disease condition |
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| Differential diagnosis |
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| Order, may perform, & interpret screening & diagnostic test |
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| Central line management |
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| Disorders – Emergencies | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Anaphylaxis |
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| Cardiac arrest |
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| Seizures |
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| Minor head injuries |
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| Animal bites |
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| Ingestions and poisonings |
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| Overdose of sedative, hypnotics, opiates |
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| Snake bites |
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| Minor burns |
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| Shock |
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| Open wounds |
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| Collaboration | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Family, support system, community resources |
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| Consulting with Physicians |
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| Consulting with Pharmacists |
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| Consulting with Speech Therapist |
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| Consulting with Dietician and Diet Aide |
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| Consulting with Occupational Therapist |
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| Referral to Pastoral Services |
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| Respiratory | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Croup |
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| Influenza |
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| Tracheobronchitis |
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| Bronchitis |
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| COPD (chronic obstructive pulmonary disease) |
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| Asthma |
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| URI (upper respiratory infection) |
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| Obstructive Sleep Apnea |
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| Viral |
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| Bacterial |
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| Bacterial |
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| Nonbacteria |
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| Oxygen administration |
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| Liquid oxygen |
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| IPPB machine use |
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| Tracheotomies |
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| Interpret ABG (blood gases) |
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| Intubations |
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| Sputum Collection |
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| Cardiovascular System | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Congestive heart failure |
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| Chronic obstructive pulmonary disease |
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| Stasis ulcer of lower extremities |
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| Angina |
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| Pericarditis |
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| Coronary artery disease |
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| Functional murmurs |
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| Congenital heart disease |
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| Hypertension |
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| ASHD (arteriosclerotic heart disease) |
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| Dyslipidemia |
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| PVD (peripheral vascular disease) |
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| Peripheral neuropathy |
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| Interpreting 12 lead EKG’s |
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| OB/GYN | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Candida vaginitis |
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| Dysmenorrhea |
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| Abnormal pap smear findings |
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| Pap smears |
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| Trichomonal vaginitis |
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| Atrophic vaginitis |
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| Fibrocystic breast disease |
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| Menopause |
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| Intrapartum medications |
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| Bartholin's cyst/abscess |
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| Preparation for childbirth |
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| Pregnancy - diagnosis and referral |
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| Pain relief in active phase of labor |
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| Medications in the third stage |
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| Dysfunctional uterine bleeding |
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| Medications in the postpartum phase |
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| Rh blood factor |
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| Mastitis |
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| Birth control methods |
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| Prenatal care |
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| Fetal well-being |
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| Nausea and vomiting with pregnancy |
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| Pap smears |
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| Pregnancy test kits |
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| GI System | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Constipation |
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| Diarrhea (simple) |
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| Acute gastroenteritis |
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| Cholecystitis |
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| Pyloric stenosis |
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| Colic |
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| Appendicitis |
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| Naso-gastric tubes |
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| Gastrostomy Care |
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| Skin | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Warts |
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| Basal cell carcinoma |
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| Scabies |
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| Impetigo |
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| Diaper dermatitis |
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| Acne |
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| Folliculitis |
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| Furuncles |
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| Carbuncles |
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| Herpes Simplex |
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| Herpes Zoster |
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| Malignant melanoma |
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| Pityriasis Rosea |
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| Contact dermatitis |
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| Tinea corporis |
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| Tinea pedis |
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| Staph infections |
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| Wound care |
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| Single layer wound closure |
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| Incision and drainage |
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| Excisions |
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| Ears, Nose and Throat | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Epistaxis |
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| Otitis externa |
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| Serous otitis media |
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| Acute purulent otitis media |
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| Allergic rhinitis |
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| Pharyngitis |
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| Oral candidiasis |
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| Eye | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Conjunctivitis |
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| Strabismus |
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| Chalazion |
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| Stye |
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| Visual acuity |
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| Fluorescein staining of eyes |
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| Audiometry |
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| Tympanometry |
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| Musculoskeletal | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Osteoporosis |
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| Osteomyelitis |
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| Rheumatoid arthritis |
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| Juvenile diabetes |
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| Gout |
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| Minor sprains and strains |
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| Osteoarthritis |
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| Carpal tunnel syndrome |
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| Scoliosis |
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| Tendonitis |
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| Bursitis |
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| Muscular dystrophy |
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| Parasitic Infections | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Pinworms |
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| Ascariasis |
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| Pediculosis |
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| Genitourinary System | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Syphilis |
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| Chlamydia |
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| Herpes |
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| Cystitis |
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| Pyelonephritis |
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| Urinary tract infection |
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| Benign prostatic hypertrophy |
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| Vulvovaginitis |
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| Hypospadias |
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| Hydrocele |
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| Gonococcal infections |
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| Prostatitis |
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| Catheter Care |
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| Incontinence care-bowel |
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| Dermal ulcers |
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| Enemas/ Suppositories/ Fecal |
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| Urine collection |
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| Nervous System | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Vasovagal syncope |
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| Migraine headaches |
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| Multiple sclerosis |
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| Headaches |
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| Head injury |
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| Tension |
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| Anxiety |
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| Parkinson’s |
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| Alzheimer’s |
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| Bell’s Palsy |
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| TIA (transient ischemic attacks) |
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| Trigeminal neuralgia |
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| Endocrine | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Type I diabetes mellitus |
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| Type II diabetes mellitus |
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| Graves disease |
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| Addison's disease |
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| Juvenile diabetes |
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| Hypoglycemia |
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| Hypothyroidism |
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| Hematological | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Folic acid deficiency anemia |
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| Aplastic anemia |
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| Iron deficiency |
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| Sickle cell anemia |
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| Pernicious anemia |
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| Hemoglobinmeter |
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| Psychosocial | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Depression |
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| Suicide |
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| Obesity |
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| Grief |
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| Anxiety |
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| Anorexia |
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| Bulimia |
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| Drug Therapy | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Prescription |
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| Over the counter (OTC) |
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| Herbal drugs |
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| Knowledge of pharmacology |
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| Knowledge of pharmacokinetics |
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| Knowledge of drug interactions |
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| Knowledge of side effects |
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| Allergic reactions |
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| Anaphylaxis reaction |
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| TPN/Lipid Management |
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| Management/Titration of IV Therapies |
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| IV/PO Antibiotic Therapy and understanding of cultures |
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| Dispensing Medication | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Monitoring drug therapy |
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| Management of controlled substances |
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| Injections |
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| Non-Pharmacologic Interventions | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Medical nutrition therapy |
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| Exercise |
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| Cessation of substance abuse (alcohol, tobacco) |
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| Mental health issues (stress management, depression) |
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| Obesity management |
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| Tube Feeding Management |
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| Miscellaneous | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Public health and health promotion |
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| Research |
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| Quality assurance |
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| Leadership and teaching skills |
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| Legal and ethical issues |
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| Confidentiality |
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| Cultural awareness |
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| Self evaluation to improve patient care |
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| Continuing education |
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| Working within scope of practice |
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| Discharge planning / collaboration |
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| Suturing |
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| Cell biopsy |
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| Starting IV |
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| Casting and splinting |
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| Radiographic interpretation (initial) |
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| Informed consent |
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| Explanation to patient/family |
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| Documentation |
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| Venipuncture |
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| Ultrasounds |
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| Programs | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| OSHA (Occupational Safety and Health Administration) |
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| Medicare and Medicaid |
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| CLIA waiver (Clinical Laboratory Improvement Amendments) |
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| TJC (The Joint Commission) |
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| HEDIS (Health Plan Employer Data and Information Set) |
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| DQIP (Diabetes Quality Improvement Program) |
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| HIPAA (Health Insurance Portability & Accountability Act) |
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| HCAHPS |
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| Age Specific Competencies | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Newborn/neonate (birth-30 days) |
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| Infant (31 days-1 year) |
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| Toddler (ages 2-3 years) |
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| Preschool (ages 4-5 years) |
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| School age (ages 6-12 years) |
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| Adolescents (ages 13-21 years) |
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| Young adult (ages 22-39 years) |
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| Adults (ages 40-64 years) |
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| Older adult (ages 65-79 years) |
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| Elderly (ages 80+ years) |
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