Physical Therapy Self Assessment

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1 Physical Therapy 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 Work Settings Adult/adult ICU Children s hospital General acute care Home health care Outpatient neuro Outpatient ortho Pediatrics/PICU Psychiatric hospital Rehabilitation hospital School setting Early intervention Skilled care facility Subacute Orthopedics Upper extremities Arthritis programs Back syndrome Cervical injuries Chronic fatigue syndrome Fibromyalgia Halo traction Hand injury Hip fracture Kyphoplasty Cross Country Healthcare, Inc. Rev. 03/13 F0069 Physical Therapy 1 of 5

2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Orthopedics - cont. Manual therapy Mobilization techniques Pelvic fracture Postpolio syndrome Shoulder injuries TMJ dysfunction Total hip/total knee Total joint replacement Total shoulder/cpm Neurologic ALS Brain tumors Cerebral palsy Multiple sclerosis Muscular dystrophy Polio/post polio syndrome Spinal cord injury Adaptive equipment Functional splinting Neurodevelopmental testing (NDT) Head trauma Glasgow coma scale Stroke rehabilitation Wheelchair prescription Pediatrics Activities of daily living Adaptive Developmental disability Equipment assessment Individualized education programs Neurodevelopmental testing (NDT) Orthotics Sequencing testing Cross Country Healthcare, Inc. Rev. 03/13 F0069 Physical Therapy 2 of 5

3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Sports Medicine Biodex Bracing/joint Cybex Immobilization Lido Medical expenses (Norwegian) Nautilus/eagle Orthotron/kinetron Stabilization techniques Swiss ball Taping/strapping Prosthetics/Orthotics Dynamic splints LE prosthetics Protonics Removeable rigid dressings Serial casting Static splints UE prosthetics Modalities Anodyne Biofeedback Edema massage Fluidotherapy Iontophoresis JOBST compression pump Muscle stimulation Paraffin bath Phonophoresis TENS Therapeutic pool Ultrasound Cross Country Healthcare, Inc. Rev. 03/13 F0069 Physical Therapy 3 of 5

4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Other Burn management Cardiac rehabilitation Chest physical therapy DME ordering FIM scoring Job task analysis Lymphedema management OASIS assessment for home care Obstetrics in physical therapy Tone management/spasticity Wheelchair ordering for SCI patients Work capacity evaluation Work hardening Wound care Knowledge of payment sources Medicare Medicaid MDS General Skills Patient/family teaching Patients in isolation Patients in restraints Initial evaluation Lift/transfer devices Specialty beds End of life care/palliative care Computerized Charting Cerner EPIC McKesson Meditech National Patient Safety Goals Accurate patient identification Effective communication Cross Country Healthcare, Inc. Rev. 03/13 F0069 Physical Therapy 4 of 5

5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) General Skills - cont. Pain assessment & management Infection control Universal precautions Care of patients in isolation Minimize risk of falls Prevention of pressure ulcers Age Specific Competencies Infant (birth to 1 year) Toddler (ages 1-3 years) Preschooler (ages 3-5 years) Childhood (ages 6-12 years) Adolescents (ages years) Young Adults (ages years) Adults (ages years) Older Adults (ages years) Elderly (ages 80+ years) 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 2012 Cross Country Healthcare, Inc. Rev. 03/13 F0069 Physical Therapy 5 of 5

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