Professional Staffing

NICU COMPETENCY SELF ASSESSMENT

Name
Social Security #
Date
Please choose your level of experience in each of the following.
CARDIOVASCULAR
Assessment
Auscultation-rate/rhythm	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Heart sounds/murmurs	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Blood pressure/non-invasive (Dinamap)	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Blood pressure (arterial lines)	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Pulses/perfusion	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Hemodynamic monitoring	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care on neonate with
Congenital heart disease	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Hemodynamic instability	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Post cardiac surgery	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Cardiac arrest	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Hypovolemic shock	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
NEUROLOGICAL
Assessment
Neurological status	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Drug withdrawal/abstinence scoring	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Intracranial pressure monitoring	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of neonate with
External V.P. shunt/reservoirs	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
ICP monitoring	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Meningitis	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Seizures	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Neurological development/positioning	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Spinal disorders	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
GASTROINTESTINAL
Assessment
Abdominal girth	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Bowel sounds	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Palate	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Suck/swallow pattern	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Feeding intolerance	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Feedings
Bottle	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Assist with breast feeding	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Breast milk handling/storage	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Placement of OGT/NGT/NdT	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Gavage	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Reflux precautions	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Test for occult blood	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of neonate with Cleft lip/palate	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
(NEC) necrotizing enterocolitis	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Inguinal hernia	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Tracheoesophogeal fistala (TEF)	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Colostomy/ileostomy	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Gastroschisis/omphalocele	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
GI bleeding	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Post abdominal surgery	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
RENAL/GU
Collection of urine specimens/catheter/diapers	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Peritoneal dialysis	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Assist & post circumcision	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Test & interpret urine abnormalities	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Insertion of urinary catheter	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of neonate with
Acute renal failure	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Disseminating intravascular coagulation	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Disorders of external/internal organs	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Malformations of GU tract/kidney	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
PAIN MANAGEMENT
Assessment of pain level pre & post procedure	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of neonate with
Sedation	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
INFECTIOUS DISEASES
Interpretation of lab results	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
CBC/Diff	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Cultures	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Maternal lab results	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Assist with lumbar puncture	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Collection of culture specimens	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of neonate with
Neonatal sepsis	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
HIV positive mother	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Hepatitis surface antigen positive mother	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Immunizations – medications
HIB/polio/DPT	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
HBIE	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
HBV	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Respiagam/synergis phrophylaxis	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Isolations techniques & procedures	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Universal precautions	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
PULMONARY
Assessment
Breath sounds	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Chest exam/auscultation	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Interpretation of lab results	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Obtaining blood gases	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Suctioning
Nasal/oral airway	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Open ETT catheter	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
In line suction	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Oxygen therapy
Nasal cannula	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Trach collar	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Anesthesia bag/mask	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Self-inflating bag/mask	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Oxyhood	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Nebulizer	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Pulse oximeter	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Intubation
Assist with intubation	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Extubation	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Indotracheal tube stabilization	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Apnea monitor	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Ventilator care
CPAP/PEEP	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
High frequency jit ventilator	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
In home ventilator	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
IMV	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Pressure ventilator	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Volume ventilator	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Nitric oxide therapy	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of neonate with
Brochopulmonary dysplasia	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Fresh tracheostomy	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Diaphragmatic hernia	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Persistant pulmonary hyptertension	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Respiratory distress hyptertension	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Pneumothorax	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
MAS	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Respiratory failure	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
ENDOCRINE/METABOLIC
Assessment of fluid & electrolyte balance	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Interpretation of lab results	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Accucheck, dextrostix, glucometer	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of IDM (hyperglycemia/hypoglycemia)	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
PHLEBOTOMY/IV THERAPY
Administration of blood products	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Starting IV	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Site & patency assessment	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
TPN	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Drawing venous blood	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Drawing blood from central line	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Delivery systems/IV pump & syringe pump	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of neonate with
Hickman	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Broviac	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Groshong	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Percutaneous arterial line/drsg	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
PICC (peripherally inserted central catheter	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Umbilical artery line	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Umbilical venus line	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
PIV	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
MEDICATIONS
Anticonvulsant	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Vasoactive drips	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
NaHCO3	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Epinephrine	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Prostaglandin	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Aminophylline/caffeine	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Insulin drip	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Steriods	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
MISCELLANEOUS
Attending high risk deliveries	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
APGAR scoring	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Gestational age
Ballard	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Dubowitz	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Thermoregulation
Isolette with humidity	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Radiant warmer	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Temperature (auxillary/rectal/skin)	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Bed Scale
Care of extremely low birthweight	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Care of infant under phototherapy	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Eye exam r/o retinopathy	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Hearing screen	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Bereavement/post mortem	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Consents	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Preparation for transport/transfer	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Pyxis	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Computerized charting	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)

2024 NATIONAL PATIENT SAFETY GOALS
NPSG.01.01.01 • Identify patients correctly	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
• Use patients name and date of birth	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
• Make sure correct patient gets the correct medicine and treatment	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Improve staff communication
NPSG.02.03.01 Get important test results to the right staff person on time.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Use medicines safely
NPSG.03.04.01 Before a proceedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
NPSG.03.05.01 Take extra care with patients who take medicines to thin their blood.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
NPSG.03.06.01 Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit their doctor.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Use Alarms Safely
NPSG.06.01.01 Make improvements to ensure that alarms on medical equipment are heard and responded to on time.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Prevent infection
NPSG.07.01.01 Use the hand cleaning guidelines from the Centers of Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Identify patient safety risks
NPSG.15.01.01 Reduce the risk for suicide.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Improve health care equity
NPSG.16.01.01 Improving health care equity is a quality and patient safety priority. For example, health care disparities in the patient population are identified and a written plan describes ways to improve health care equity.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Prevent mistakes in surgery
UP.01.01.01 Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
UP.01.02.01 Mark the correct place on the patients body where the surgery is to be done.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
UP.01.03.01 Pause before the surgery to make sure that a mistake is not being made.	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)

COMPUTERIZED CHARTING
Health Connect	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Meditech	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Cerner	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
McKesson	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
EPIC	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Camis	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Affinity	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Automated medication dispensing	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)
Bar coding for medication administration	Theory Only Some Experience Experience (Performs without assistance) Very Experienced (Performs Well)

AGE SPECIFIC CRITERIA
Please select the box next to each age group that you have expertise in
Neonate Newborn Infant & toddler 30 days – 3 years
YEARS EXPERIENCE
Please indicate number of years of experience in the following disciplines.
Level II Nursery	years
Level III Nursery	years

All the information on this page is true and accurate to the best of my knowledge. By completing this form, I am authorizing Professional Staffing to release this information to the appropriate client facilities in consideration of employment as a registry, local traveler or full traveler.

This form has been Electronically Signed and Authenticated by: Date: Please Enter Your Name and Date and then click the Submit Button

SKILLS CHECKLIST