Hospice Skills Checklist
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1 _ XXX-XX- Print Name Last 4 of SS # Date Completed Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 - No (has never done or observed) 2 - Requires Training (In-Service) - not performed within last 36 months 3 - Limited (requires assistance or training) - performed within the last 24 months 4 - d (routinely performs without assistance) - performed within the last 12 months 5 - Able to Supervise, Precept and Teach - performed within the last 6 months MEDICATIONS / IV THERAPY ADMINISTER PO MEDICATIONS ADMINISTER TOPICAL MEDICATIONS ADMINISTER IM / SQ MEDICATIONS ADMINISTER IV MEDICATIONS NEEDLE-LESS SYSTEMS INFUSION PUMPS ESTABLISH PERIPHERAL IVS DISCONTINUE PERIPHERAL IVS PAIN ASSESSMENT / MANAGEMENT ADMIN BLOOD / BLOOD PRODUCTS DRAW BLOOD FOR LAB STUDIES CENTRAL VENOUS LINES (CVL) HICKMAN / BROVIAC CATHETERS PCA / CADD INFUSAID PORT-A-CATH INFUSE-A-PORT Version: 07/03/2012 Page 1 out of 7
2 CANCER THERAPY - RADIATION THERAPY (RT) ELECTROMAGNETIC (XRAYS, GAMMA RAYS) PARTICULATE (ALPHA, BETA) EXTERNAL BEAM THERAPY KNOWLEDGE OF EARLY EFFECTS OF RT KNOWLEDGE OF INTERM. EFFECTS OF RT KNOWLEDGE OF LATE EFFECTS OF RT BRACHYTHERAPY (SEALED SOURCES) INTERSTITIAL RADIATION THERAPY INTRACAVITARY RADIATION THERAPY INTRALUMINAL RADIATION THERAPY RADIOPHARMACEUTICAL (UNSEALED SOURCES) TRACER DOSE THERAPEUTIC DOSE SURGICAL INTERVENTION CURATIVE SURGERY DIAGNOSTIC SURGERY MECHANICAL DEVICE INSERTION PALLIATIVE SURGERY PROPHYLACTIC SURGERY RECONSTRUCTIVE SURGERY REHABILITATIVE SURGERY BONE MARROW TRANSPLANT - ALLOGENIC BONE MARROW TRANSPLANT - SYNGENIC CARE OF ONCOLOGICAL PATIENT HEAD, NECK, CHEST HEMATOLOGIC SYSTEM GASTROINTESTINAL TRACT REPRODUCTIVE SYSTEM SKIN (MELANOMAS / NONMELANOMAS) Version: 07/03/2012 Page 2 out of 7
3 CARE OF ONCOLOGICAL PATIENT URINARY TRACT EMERGENCIES CARDIAC TAMPONADE DISSESMINATED INTRAVASCULAR COAGULATION HYPERCALCEMIA ORGAN OBSTRUCTION SEPSIS SPINAL CORD COMPRESSION SUPERIOR VENA CAVAE SYNDROME TUMOR LYSIS SYNDROME FAMILY / PSYCHOSOCIAL NEEDS PATIENT / FAMILY EDUCATION ADVANCE DIRECTIVES ACUTE PHASE CHRONIC PHASE BEREAVEMENT PHASE TERMINAL PHASE AFTER TREATMENT (SURVIVORSHIP) ONCOLOGY HEALTH CARE SETTINGS ADULT PEDIATRICS CANCER CENTER RADIATION ONCOLOGY SURGICAL ONCOLOGY BONE MARROW UNIT RESEARCH / CLINICAL TRIALS SUBACUTE / SKILLED NURSING HOME HEALTH HOSPICE CLINIC - RISK ASSESS / SCREENING / DIAGNOSIS Version: 07/03/2012 Page 3 out of 7
4 ONCOLOGY HEALTH CARE SETTINGS CLINIC - SURGERY / GYN CLINIC - MEDICAL / HEMATOLOGY CLINIC - IMMUNOLOGY / INFECTIOUS ANTINEOPLASTIC AGENTS - ROUTES OF ADMINISTRATION ORAL / SQ / IM INTRAVENOUS INTRAARTERIAL INTRATHECAL / INTRAVENTRICULAR INTRAPERITONEAL (TENCKHOFF CATHETER) INTRAPLEURAL INTRAVESICULAR ALKYLATING AGENTS BULSULFAN (MYLERAN) CHLORAMBUCIL (LEUKERAN) CISPLATIN (PLATINOL) CYCLOPHOSPHAMIDE (CYTOXAN) MECHLORETHAMINE (MUSTARGEN) ANTIMETABOLITES CYTARABINE (ARA-C) FLUOROURACIL (5-FU) MERCAPTOPURINE (6-MP) METHOTREXATE LEUCOVORIN RESCUE PROTOCOL ANTINEOPLASTIC ANTIBIOTICS BLEOMYCIN DACTINOMYCIN (ACTINOMYCIN) DAUNORUBICIN (DAUNOXOME) DOXORUBICIN (ADRIAMYCIN) PLANT ALKALOIDS PACLITAXEL (TAXOL) Version: 07/03/2012 Page 4 out of 7
5 PLANT ALKALOIDS VINBLASTINE (VELBAN) VINCRISTINE (ONCOVIN) HORMONAL ANTINEOPLASTICS LEUPROLIDE (LUPRON) MEGESTROL (MEGACE) TAMOXIFEN (NOLVADEX) TESTOLACTONE (TESLAC) STAFF MINIMIZE RISK OF EXPOSURE DURING PREPARATION DURING ADMINISTRATION DURING DISPOSAL TREATMENT SIDE EFFECTS - RECOGNITION & MANAGEMENT OF ANXIETY / DEPRESSION METABOLIC ALTERATIONS HYPERSENSITIVITY FATIGUE HEMATOPOIETIC ANEMIA LEUKOPENIA THROMBOCYTOPENIA GASTROINTESTINAL ANOREXIA / DEHYDRATION NAUSEA / VOMITING CONSTIPATION / DIARRHEA MUSCOSITIS / ULCERATION HEPATIC TOXICITY INTEGUMENTARY ALOPECIA DERMATITUS HYPERPIGMENTATION Version: 07/03/2012 Page 5 out of 7
6 GENITOURINARY CYSTITIS RENAL TOXICITY CARDIOVASCULAR CARDIAC TOXICITY PHLEBITIS EXTRAVASATION NEUROLOGIC NEUROTOXICITY OTOTOXICITY METABOLIC ENCEPHALOPATHY PERIPHERAL NEUROPATHY PULMONARY FIBROSIS PNEUMONITIS EDEMA REPRODUCTIVE INFERTILITY CHANGES IN LIBIDO ERECTILE DYSFUNCTION NUTRITION ASSESS NUTRITIONAL STATUS ASSESS / MANAGE NUTRITIONAL IMPAIRMENT INTERPRETATION OF LAB VALUES ORAL FEEDINGS ENTERAL TUBE FEEDING PERIPHERAL PARENTERAL NUTRITION (PPN) CENTRAL TPN CLASSIFICATION OF NEOPLASMS STAGING - TNM SYSTEM Version: 07/03/2012 Page 6 out of 7
7 CLASSIFICATION OF NEOPLASMS TISSUE OF ORIGIN BIOLOGIC BEHAVIOR DEGREE OF CELL DIFFERENTIATION ANATOMIC SITE AGE APPROPRIATE CARE 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) The information represented above is true and correct to the best of my knowledge. I also authorize Specialty Professional Services, Corp to share the above skills checklist with its facility clients. Signature Date Completed Fax: Version: 07/03/2012 Page 7 out of 7
Oncology Skills Checklist
_ XXX-XX- Print Name Last 4 of SS # Date Completed Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values
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