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Ambulatory RN
Ambulatory RN
Name
First
Last
Email
Phone
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale:
No Experience
Theory or observation only during the past 12 months
Limited Experience
Performed less than 12 times within the past 12 months and may need a review
Experienced
Performed at least once per month within the past 12 months and may need minimal assistance
Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient
Age
No Experience
Limited Experience
Experienced
Highly Skilled
Newborn (birth-30 days)
Infant (30 days - 1 year)
Toddler (1 - 3 years)
Preschooler (3 - 5 years)
School Age (5 - 12 years)
Adolescents (12 - 18 years)
Young Adults (18 - 39 years)
Middle Adults (39 - 64 years)
Older Adults (64+ years)
General Skills
No Experience
Limited Experience
Experienced
Highly Skilled
Standard Precautions
Isolation Precautions
Adult Respiratory/ Cardiac Arrest
Pediatric Respiratory/Cardiac Arrest
Defibrillators
Patient/ Family Education
Crash Carts
Admit and Assess Patients
Automated Med Dispensing Systems
Electronic Documentation
Obtaining Cultures (Blood, Sputum, Swab, Urine)
Advance Directives
Collect Appropriate Data
Discharge Teaching
Preoperative Teaching
Patient Prep
Cardiovascular
No Experience
Limited Experience
Experienced
Highly Skilled
Assess Heart Tones
Bedside Tele Monitoring
Interpretation of Coagulation Studies
Perform Pulse/ Circulation Checks
Pre-Post Op Pacemaker Care
Pulmonary
No Experience
Limited Experience
Experienced
Highly Skilled
Assess Breath Sounds
Apply Oxygen
Interpret ABGs
Thoracentesis
Oximetry
Neurology
No Experience
Limited Experience
Experienced
Highly Skilled
Assess Neurological Signs
Epidurals
Selective Nerve Root Blocks
Assess Level of Consciousness
GI
No Experience
Limited Experience
Experienced
Highly Skilled
Insertion/ Monitoring NG Tubes
Assessment
Flexible Sigmoidoscopy
Hemorrhoid Banding
Liver Biopsy
Paracentesis
Lap Band Surgery
GU
No Experience
Limited Experience
Experienced
Highly Skilled
Bladder Biopsy
Cystoscopy
Urethral Dilation
Nephrostomy
Kidney Biopsy
Suprapubic Catheter
Prostate Biopsy
Endocrine
No Experience
Limited Experience
Experienced
Highly Skilled
Care of Diabetic Patient
Diabetic Teaching
Blood Glucose Testing
ENT and Mouth
No Experience
Limited Experience
Experienced
Highly Skilled
Prosthodontics -Restorative Dentistry
Mouth Biopsy
Myringotomy
Maxillofacial Prosthetics
Nose Biopsy
Thyroid Aspirate Biopsy
Fiberoptic Laryngoscopy
Tonsillectomy
Wounds/Integument
No Experience
Limited Experience
Experienced
Highly Skilled
Application of Burn Dressing
Dressing Changes
Debridement of Wound
Wound Care
Wound Vac
OB / GYN
No Experience
Limited Experience
Experienced
Highly Skilled
Electrodesiccation and Curettage (ED7C)
Assist with In-Office Procedures
Ortho
No Experience
Limited Experience
Experienced
Highly Skilled
Arthrocentesis
External Hardware and Pin Care
Arthroscopy
Open Reduction and Internal Fixation
Closed Reduction and Internal Fixation
Trigger Point Injections
Plastics
No Experience
Limited Experience
Experienced
Highly Skilled
Rhinoplasty
Liposuction
Nipple Reconstruction
MOHS Repairs
Blepharoplasty
Mole/ Cyst Removal
General Medications/Therapeutic Interventions
No Experience
Limited Experience
Experienced
Highly Skilled
Administer IM and SQ Medications
Administer Inhalation Medications
Administer PO Medications
Bladder Irrigation and Installation
Needleless System
Chemotherapy
IV Therapy
No Experience
Limited Experience
Experienced
Highly Skilled
Infusion Pumps
Peripheral IV Insertion
Syringe Pumps
Vascular Access Devices Care/ Maintenance
Administer IV Medications
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