Acute Rehab RN Acute Rehab RN 0 = No Experience / Observed Only 1 = Limited Experience / Rarely Done (<6 times/year) 2 = May Need Some Review / Occasionally Done (1 – 2 times/month) 3 = Experienced / Frequently Done (daily or weekly) Name Name First First Last Last Email: * TYPE OF FACILITY EXPERIENCE * Acute Hospital Level 1 Acute Hospital Level 2 Acute Hospital Level 3 CAH (Critical Access Hospital) Unknown or No Trauma Designation Long-Term Acute Care (LTAC) Rehab Skilled Nursing Facility (SNF) AGE OF PATIENTS CARED FOR * Newborn/Neonate (birth to 30 days) * 0 1 2 3 Infant (31 days to 12 months) * 0 1 2 3 Toddler/Preschool (13 months to 5 years) * 0 1 2 3 School Age Child/adolescent (6 years to 18 years) * 0 1 2 3 Young Adults/Middle Adult (19 years to 64 years) * 0 1 2 3 Older Adults/Elderly (65+ years) * 0 1 2 3 GENERAL SKILLS * Care of Patient in Restraints * 0 1 2 3 Automated Med Dispensing Systems * Accudose Metro Omnicell Promanager Rx Pyxis N/A Other Automated Med Dispensing Systems: * Electronic Documentation * Allscripts Care360 Cerner eCLinicalWorks EPIC MACLAB McKesson Meditech PACS Soarian N/A Other Electronic Documentation: * IV Pumps * Alaris Alibaba Bard Baxter Braun CADD IVAC Zynomed N/A Other IV Pumps: * Peripheral IV Insertion, Care and Maintenance 0 1 2 3 Access/Management of Implanted Ports 0 1 2 3 Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.) 0 1 2 3 Cardiac Monitoring/Interpretation 0 1 2 3 PCA/Epidural pumps 0 1 2 3 Titration of drips 0 1 2 3 Administration of Blood/Blood Products 0 1 2 3 Knowledge of “Do Not Use Abbreviations” 0 1 2 3 Do you have charge/supervisor experience? Yes No 0 1 2 3 Knowledge of current Joint Commission National Patient Safety Goals 0 1 2 3 Knowledge/familiarity with HCAHPS scores 0 1 2 3 NEUROLOGIC – Care of patients with: * Pre/Post Neuro Surgery * 0 1 2 3 Basal Skull Fracture * 0 1 2 3 Closed Head Injuries * 0 1 2 3 Coma * 0 1 2 3 Delirium Tremens * 0 1 2 3 Encephalitis * 0 1 2 3 Meningitis * 0 1 2 3 Spinal Cord Injuries * 0 1 2 3 Seizures * 0 1 2 3 Overdose * 0 1 2 3 Stroke/TIA * 0 1 2 3 Guilliane Barre Syndrome * 0 1 2 3 Alzheimer’s Disease * 0 1 2 3 Externalized AV Shunt * 0 1 2 3 Post Craniotomy * 0 1 2 3 CARDIAC – Care of patients with: * Pre/Post Cardiac Surgery * 0 1 2 3 Cardiac Transplant * 0 1 2 3 Abdominal Aortic Aneurysm/Bypass * 0 1 2 3 Angina * 0 1 2 3 Cardiac Arrest * 0 1 2 3 Cardiomyopathy * 0 1 2 3 Femoral Poplitieal Bypass * 0 1 2 3 Myocarditis * 0 1 2 3 Post Angioplasty/Stent * 0 1 2 3 Thrombophlebitis * 0 1 2 3 CHF * 0 1 2 3 Chest Pain * 0 1 2 3 Post MI * 0 1 2 3 Temporary pacemaker * 0 1 2 3 Permanent pacemaker * 0 1 2 3 ORTHOPEDIC – Care of patients with: * Total Joint Replacement Procedures * 0 1 2 3 Fractures * 0 1 2 3 Rheumatic/Arthritic Disease * 0 1 2 3 Spinal Fusion * 0 1 2 3 Amputation * 0 1 2 3 Traction Devices * 0 1 2 3 Walking asistants (i.e. Crutches, Walker, Cane) * 0 1 2 3 RESPIRATORY – Care of patients with: * Lung Transplant * 0 1 2 3 Bronchoscopy * 0 1 2 3 Lobectomy * 0 1 2 3 Tracheostomy Tube * 0 1 2 3 COPD * 0 1 2 3 Asthma * 0 1 2 3 Pneumonia * 0 1 2 3 Pre/Post Thoracic Surgery * 0 1 2 3 Chest Tubes * 0 1 2 3 Tuberculosis * 0 1 2 3 Pneumonectomy * 0 1 2 3 Pulmonary Embolism * 0 1 2 3 Thoracotomy * 0 1 2 3 Pulmonary Edema * 0 1 2 3 Pneumothorax * 0 1 2 3 Laryngospasm * 0 1 2 3 GASTROINTESTINAL – Care of Patient with: * Post Abdominal Surgery * 0 1 2 3 Liver Transplant * 0 1 2 3 Pancreas Transplant * 0 1 2 3 Ileostomy * 0 1 2 3 Colostomy * 0 1 2 3 Inflammatory Bowel Disease * 0 1 2 3 Bowel Obstruction * 0 1 2 3 Hepatitis * 0 1 2 3 GI Bleeding * 0 1 2 3 Liver Failure * 0 1 2 3 Paralytic Ileus * 0 1 2 3 Abdominal Trauma * 0 1 2 3 RENAL/GU – Care of patients with: * Kidney Transplant * 0 1 2 3 Insertion of Catheter (Straight and Foley) * 0 1 2 3 Bladder Irrigations * 0 1 2 3 Peritoneal Dialysis * 0 1 2 3 Hemodialysis * 0 1 2 3 A-V Fistula/Shunt Care * 0 1 2 3 Suprapubic Catheter * 0 1 2 3 Nephrostomy Tube * 0 1 2 3 Nephrectomy * 0 1 2 3 Urinary Tract Infection * 0 1 2 3 Pyelonephritis * 0 1 2 3 Renal Failure * 0 1 2 3 Renal Transplant * 0 1 2 3 TURP * 0 1 2 3 Ileal Conduit * 0 1 2 3 Renal Trauma * 0 1 2 3 Renal Calculi * 0 1 2 3 ENDOCRINE – Care of patients with: * Hyperthyroidism * 0 1 2 3 Hypothyroidism * 0 1 2 3 Thyroidectomy * 0 1 2 3 Diabetes Mellitus * 0 1 2 3 Diabetes Insipidus * 0 1 2 3 Diabetic Ketoacidosis * 0 1 2 3 KNOWLEDGE AND USE OF * Insulin * 0 1 2 3 Single Type * 0 1 2 3 Mixed Insulins * 0 1 2 3 Insulin Infusion * 0 1 2 3 WOUND/SKIN – Care of Patient with: * Multiple Abdominal Wounds and Drains * 0 1 2 3 Gunshot Wound * 0 1 2 3 Stab Wound * 0 1 2 3 Lacerations * 0 1 2 3 Dressing Changes * 0 1 2 3 Pressure Relief Mattresses * 0 1 2 3 Decubitus Ulcers * 0 1 2 3 Traumatic Wounds * 0 1 2 3 Leg Ulcers * 0 1 2 3 First Degree Burns * 0 1 2 3 Second Degree Burns * 0 1 2 3 Third Degree Burns * 0 1 2 3 ADDITIONAL MEDICAL/SURGICAL SKILLS-Care of Patient With * Hemovacs * 0 1 2 3 Jackson-Pratt Drains * 0 1 2 3 Penrose Drains * 0 1 2 3 Surgical Wound Irrigations & Dressings * 0 1 2 3 INFECTIOUS DISEASE – Care of the patient with: * HIV * 0 1 2 3 MRSA * 0 1 2 3 CRE * 0 1 2 3 VRE * 0 1 2 3 C. Difficile * 0 1 2 3 Hepatitis * 0 1 2 3 Influenza * 0 1 2 3 Isolation Precautions * 0 1 2 3 MEDICATIONS * Antibiotics * 0 1 2 3 Antihypertensives * 0 1 2 3 anticoagulants * 0 1 2 3 Anticonvulsants * 0 1 2 3 Narcotics * 0 1 2 3 Digoxin * 0 1 2 3 Diuretics * 0 1 2 3 Steroids * 0 1 2 3 Diltiazem * 0 1 2 3 Antiemetics * 0 1 2 3 Antispasmotics * 0 1 2 3 Oral Hypoglycemics * 0 1 2 3 Inhalers * 0 1 2 3 IV Conscious Sedation * 0 1 2 3 Reversal Agents (Narcan, Romazicon) * 0 1 2 3 Attestation * I certify that the information provided above accurately reflects the education received and my experience in each of the clinical areas. I hereby authorize Explore TEK (The Company) to collect, store, and use the information provided by me according to their Privacy Policy Signature * Clear If you are human, leave this field blank. Submit
