Instructions: This checklist is
meant to serve as a general guideline for our client facilities as to the
level of your skills within your nursing specialty. Please use the scale
(PROFICIENCY)
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
(FREQUENCY)
1 = Never performed observed only
2 = Less than 6 times per year
3 = 1-2 times per month
4 = Daily or Weekly
PROFICIENCY / FREQUENCY
PROFICIENCY
FREQUENCY
Age of Patients Cared For
Newborn/Neonate (birth to 30 days)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 5 years)
School Age Child (5 years to 12 years)
Adolescents (12 years to 18 years)
Young Adults (18 years to 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)
Pediatric Respiratory/Cardiac Arrest
Adult Respiratory/Cardiac Arrest
Automated Med Dispensing Systems
Diagnostic Studies/Procedures
Multiple Sleep Latency Test (MSLT)
Maintenance of Wakefulness Test (MWT)
Nocturnal Penile Tumescence
Split-Night Polysomnogram
Patient Positioning/Preparation
Drawing Arterial Blood Gases (ABGs)
Respiratory Disturbance Index (RDI)
Apnea-Hypopnea Index (AHI)
Seizure Recognition and Precaution
Transient Arousal Scoring Rules/Procedures