Nurse Practitioner Self Assessment
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- Everett Barton
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1 Nurse Practitioner Self Assessment 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 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date Areas Worked Emergency Urgent Care Private Practice HMO MD Office Schools Health Department Ambulatory Clinic Rural Health Clinic Psychiatric Facility Correctional Facility Mobile Medical Unit Corporate Worksite Occupational Health Rehabilitation Nursing Home/ Long-term Care Facility Women's Health Clinic Government Health Agency Hospice/Palliative Care With Diabetes Contractures Bedridden residents Splinting of extremities Local infiltration Comprehensive physical assessment Acute disease condition Differential diagnosis Order, may perform, & interpret screening & diagnostic test Central line management Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 1 of 10
2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Disorders Emergencies Anaphylaxis Cardiac arrest Seizures Minor head injuries Animal bites Ingestions and poisonings Overdose of sedative, hypnotics, opiates Snake bites Minor burns Shock Open wounds Collaboration Family, support system, community resources Consulting with Physicians Consulting with Pharmacists Consulting with Speech Therapist Consulting with Dietician and Diet Aide Consulting with Occupational Therapist Referral to Pastoral Services Respiratory Croup Influenza Tracheobronchitis Bronchitis COPD (chronic obstructive pulmonary disease) Asthma URI (upper respiratory infection) Obstructive Sleep Apnea Pneumonia: Viral Bacterial Sinusitis: Bacterial Nonbacterial Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 2 of 10
3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Respiratory- cont. Oxygen administration Liquid oxygen IPPB machine use Tracheotomies Interpret ABG (blood gases) Intubations Sputum Collection Cardiovascular System Congestive heart failure Chronic obstructive pulmonary disease Stasis ulcer of lower extremities Angina Pericarditis Coronary artery disease Functional murmurs Congenital heart disease Hypertension ASHD (arteriosclerotic heart disease) Dyslipidemia PVD (peripheral vascular disease) Peripheral neuropathy Interpreting 12 lead EKG s OB/GYN Candida vaginitis Dysmenorrhea Abnormal pap smear findings Pap smears Trichomonal vaginitis Atrophic vaginitis Fibrocystic breast disease Menopause Intrapartum medications Bartholin's cyst/abscess Preparation for childbirth Pregnancy - diagnosis and referral Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 3 of 10
4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) OB/GYN - cont. Pain relief in active phase of labor Medications in the third stage Dysfunctional uterine bleeding Medications in the postpartum phase Rh blood factor Mastitis Birth control methods Prenatal care Fetal well-being Nausea and vomiting with pregnancy Pap smears Pregnancy test kits GI System Constipation Diarrhea (simple) Acute gastroenteritis Cholecystitis Pyloric stenosis Colic Appendicitis Naso-gastric tubes Gastrostomy Care Skin Warts Basal cell carcinoma Scabies Impetigo Diaper dermatitis Acne Folliculitis Furuncles Carbuncles Herpes Simplex Herpes Zoster Malignant melanoma Pityriasis Rosea Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 4 of 10
5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Skin - cont Contact dermatitis Tinea corporis Tinea pedis Staph infections Wound care Single layer wound closure Incision and drainage Excisions Ears, Nose and Throat Epistaxis Otitis externa Serous otitis media Acute purulent otitis media Allergic rhinitis Pharyngitis Oral candidiasis Eye Conjunctivitis Strabismus Chalazion Stye Visual acuity Fluorescein staining of eyes Audiometry Tympanometry Musculoskeletal Osteoporosis Osteomyelitis Rheumatoid arthritis Juvenile diabetes Gout Minor sprains and strains Osteoarthritis Carpal tunnel syndrome Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 5 of 10
6 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Musculoskeletal - cont. Scoliosis Tendonitis Bursitis Muscular dystrophy Parasitic Infections Pinworms Ascariasis Pediculosis Genitourinary System Syphilis Chlamydia Herpes Cystitis Pyelonephritis Urinary tract infection Benign prostatic hypertrophy Vulvovaginitis Hypospadias Hydrocele Gonococcal infections Prostatitis Catheter Care Incontinence care-bowel Dermal ulcers Enemas/ Suppositories/ Fecal Urine collection Nervous System Vasovagal syncope Migraine headaches Multiple sclerosis Headaches Head injury Tension Anxiety Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 6 of 10
7 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Nervous System - cont. Parkinson s Alzheimer s Bell s Palsy TIA (transient ischemic attacks) Trigeminal neuralgia Endocrine Type I diabetes mellitus Type II diabetes mellitus Graves disease Addison's disease Juvenile diabetes Hypoglycemia Hypothyroidism Hematological Folic acid deficiency anemia Aplastic anemia Iron deficiency Sickle cell anemia Pernicious anemia Hemoglobinmeter Psychosocial Depression Suicide Obesity Grief Anxiety Anorexia Bulimia Drug Therapy Prescription Over the counter (OTC) Herbal drugs Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 7 of 10
8 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Drug Therapy - cont. Knowledge of pharmacology Knowledge of pharmacokinetics Knowledge of drug interactions Knowledge of side effects Knowledge of potential adverse reactions: Allergic reactions Anaphylaxis reaction TPN/Lipid Management Management/Titration of IV Therapies IV/PO Antibiotic Therapy and understanding of cultures Dispensing Medication Monitoring drug therapy Management of controlled substances Injections Non-Pharmacologic Interventions Medical nutrition therapy Exercise Cessation of substance abuse (alcohol, tobacco) Mental health issues (stress management, depression) Obesity management Tube Feeding Management Miscellaneous Public health and health promotion Research Quality assurance Leadership and teaching skills Legal and ethical issues Confidentiality Cultural awareness Self evaluation to improve patient care Continuing education Working within scope of practice Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 8 of 10
9 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Miscellaneous - cont. Discharge planning / collaboration Suturing Cell biopsy Starting IV Casting and splinting Radiographic interpretation (initial) Informed consent Explanation to patient/family Documentation Venipuncture Ultrasounds Programs OSHA (Occupational Safety and Health Administration) Medicare and Medicaid CLIA waiver (Clinical Laboratory Improvement Amendments) TJC (The Joint Commission) HEDIS (Health Plan Employer Data and Information Set) DQIP (Diabetes Quality Improvement Program) HIPAA (Health Insurance Portability & Accountability Act) HCAHPS Age Specific Competencies Newborn/neonate (birth-30 days) Infant (31 days-1 year) Toddler (ages 2-3 years) Preschool (ages 4-5 years) School age (ages 6-12 years) Adolescents (ages years) Young adult (ages years) Adults (ages years) Older adult (ages years) Elderly (ages 80+ years) Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 9 of 10
10 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Please list any Additional Skills: Additional training: Additional equipment: Fax to: The information on this and all preceding pages is true and correct. Signature Date 2014 Cross Country Healthcare, Inc. Rev. 10/14 F0841 Nurse Practitioner 10 of 10
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