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Pediatric Skills Checklist
Name: ________________________________________ Date: _______________
Indicate your level of experience rating with one of the following:
A – No Experience.
B – Minimal Experience - need review and supervision, have performed at least once.
C – Competent - able to perform independently.
D – Expert - able to act as resource to others.



Initials _________
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1. Assessment – level of consciousness Initials _________
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2. Interpretation of lab results – Serum electrolytes Initials _________
X:\TMP - Kristy to Convert\Peds skills cklst & JD.doc E. RENAL/GENITOURINARY
Initials _________
X:\TMP - Kristy to Convert\Peds skills cklst & JD.doc G. HEMATOLOGY/ONCOLOGY
3. Equipment and procedures – reverse isolation d. Disseminated intravascular coagulation (DIC) H. MEDICATION ADMINISTRATION FOR CHILDREN
a. Administration of blood/blood products Initials _________
X:\TMP - Kristy to Convert\Peds skills cklst & JD.doc J. INFECTIOUS DISEASES
1. Interpretation of lab results – blood count b. Common childhood – communicable disease K. MISCELLANEOUS
Initials _________
X:\TMP - Kristy to Convert\Peds skills cklst & JD.doc L. WOUND MANAGEMENT
i. Use of air fluidized, low airloss beds M. PAIN MANAGEMENT

Age Specific Practice Criteria
Please check the boxes below for each age group for which you have expertise in providing
age-appropriate nursing care.
G. Young adults (18 - 39 years) H. Middle
Experience with Age Groups
Able to adapt care to incorporate normal growth and development. Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level. Can ensure a safe environment reflecting specific needs of various age groups. Initials _________
X:\TMP - Kristy to Convert\Peds skills cklst & JD.doc My pediatric experience is primarily in: (please indicate number of years)

Total years in pediatric nursing: _____ year(s)……………

Please check the boxes below and indicate the expiration date for each certificate that you
have. If you do not know the exact date, please use the last date of the specific month (e.g.,

Please read and agree to the statements below by marking the checkbox.

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Company to release this Pediatric Skills Checklist to the Client facilities in relation to consideration of employment as a Registered Nurse with those facilities. ___________________________________ ___________________

Initials _________
X:\TMP - Kristy to Convert\Peds skills cklst & JD.doc Registered Professional Nurse Job Description
Pediatric Care

Job Summary:
The Pediatric RN is responsible for managing the care of the pediatric and adult patient
requiring a surgical procedure that requires moderate to complex assessment, interventions
and levels of nursing vigilance. The Pediatric RN is responsible to the Clinical Manager
assigned to the Pediatric unit.
• Current licensure in good standing in the state of practice • Evidence of 1 year of pediatric nursing experience within the past two years; scrub • Evidence of current BLS credential mandatory; additionally, the RN may have resuscitation credentials including but not limited to ACLS & PALS Responsibilities
• Conducts an individualized patient assessment and reassessment, prioritizing the data collected based on the infant, toddler, preschool, school age, adolescent, adult or elderly patient’s immediate condition or needs within timeframe specified by client facility’s policies, procedures or protocols. • Develops individualized plan of care reflecting collaboration with other members of the • Collaborates with physician and other team members to implement orders and plan of • Provides individualize patient/family education and discharge planning customized to the infant, toddler, preschool, school age, adolescent, adult or elderly patient and his/her family. • Documents patient assessment findings, physical/psychosocial responses to nursing intervention and progress toward problem resolution and communicates these responses to team members as appropriate. • Responds to emergencies according to facility policy and procedure. • Maintains confidentiality in matters related to patient, family and client facility staff. • Provides care in a non-judgmental, non-discriminatory manner that is sensitive to the infant, toddler, preschool, school age, adolescent, adult or elderly patient’s and family’s diversity, preserving their autonomy, dignity and rights. • Reports relative indicators of patient condition to appropriate personnel during and at • Maintains current competency in pediatric nursing. RN Name: _________________________________________________________________ RN Signature: ____________________________________ Initials _________
X:\TMP - Kristy to Convert\Peds skills cklst & JD.doc 2006 Critical Access Hospital and Hospital
National Patient Safety Goals

Note: New Goals and Requirements are indicated in bold.
Goal 1
Improve the accuracy of patient identification. Use at least two patient identifiers (neither to be the patient’s room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. Improve the effectiveness of communication among caregivers. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result “read-back” the complete order or test result. Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Implement a standardized approach to “hand off” communications, including
an opportunity to ask and respond to questions.

Improve the safety of using medications. Standardize and limit the number of drug concentrations available in the organization. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (e.g., syringes, medicine cups,
basins), or other solutions on and off the sterile field in perioperative and
other procedural settings.

Reduce the risk of health care-associated infections. Initials _________
X:\TMP - Kristy to Convert\Peds skills cklst & JD.doc Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. Accurately and completely reconcile medications across the continuum of care. Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. Reduce the risk of patient harm resulting from falls. Implement a fall reduction program and evaluate the effectiveness of the program.
Note: Replacement for 9A.
Goal 10 Not applicable. Goal 11 Not applicable. Goal 12 Not applicable. Goal 13 Not applicable. Goal 14 Not applicable. Initials _________
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STRICTLY CONFIDENTIAL Application IAAF Therapeutic Use Exemptions Abbreviated Application Form [International] [Beta-2 agonists by inhalation, Glucocorticosteroids by non-systemic routes] I herby apply for approval for the therapeutic use of a prohibited substance on the IAAF Prohibited List that is subject to the Abbreviated TUE Application Procedure Please complete

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