Pediatric Competency 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 General Skills Normal growth & development 0 1 2 3 4 5 Immunizations 0 1 2 3 4 5 Provide safe environment for age specific care 0 1 2 3 4 5 Recognize signs of failure to thrive 0 1 2 3 4 5 Recognize signs of abuse/neglect 0 1 2 3 4 5 Advanced directives 0 1 2 3 4 5 Awareness of HCAHPS 0 1 2 3 4 5 Patient/family teaching 0 1 2 3 4 5 Lift/transfer devices 0 1 2 3 4 5 Specialty beds 0 1 2 3 4 5 Restrictive devices (restraints) 0 1 2 3 4 5 End of life care/pallative care 0 1 2 3 4 5 Wound assessment & care 0 1 2 3 4 5 Automated Medication Dispensing System, Pyxis, Omnicell, or other 0 1 2 3 4 5 Bar coding for medication administration 0 1 2 3 4 5 Diabetic care & education 0 1 2 3 4 5 Blood Glucose Monitoring (BGM) 0 1 2 3 4 5 Insulin administration 0 1 2 3 4 5 National Patient Safety Goals 0 1 2 3 4 5 Accurate patient identification 0 1 2 3 4 5 Effective communication 0 1 2 3 4 5 Interpretation & communication of lab values 0 1 2 3 4 5 Medication administration (PO,IM,IV,PR) 0 1 2 3 4 5 Labeling (medications & specimens) 0 1 2 3 4 5 Medication reconciliation 0 1 2 3 4 5 Anticoagulation therapy 0 1 2 3 4 5 Monitoring conscious sedation 0 1 2 3 4 5 Pain assessment & management 0 1 2 3 4 5 Use of PCA (IV, intrathecal, epidural) 0 1 2 3 4 5 Infection control 0 1 2 3 4 5 Universal precautions 0 1 2 3 4 5 Isolation 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0048 Pediatric 1 of 7
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. Minimize risk for falls 0 1 2 3 4 5 Prevention of pressure ulcers 0 1 2 3 4 5 IV Therapy Starting & maintaining peripheral IVs 0 1 2 3 4 5 Blood draw: venous 0 1 2 3 4 5 Central line care (includes Broviac/PICC/Groshong/Hickman) 0 1 2 3 4 5 Blood draw: central line 0 1 2 3 4 5 Care & management of ports 0 1 2 3 4 5 TPN & lipids 0 1 2 3 4 5 Administration of blood & blood products 0 1 2 3 4 5 Administration of chemotherapy 0 1 2 3 4 5 Monitoring chemotherapy (does not initiate) 0 1 2 3 4 5 Cardiovascular Pediatric assessment 0 1 2 3 4 5 Cardiac monitoring & emergency care 0 1 2 3 4 5 Obtains 12 lead EKG 0 1 2 3 4 5 Basic EKG interpretation 0 1 2 3 4 5 Use of rapid response teams 0 1 2 3 4 5 Cardiac arrest/cpr 0 1 2 3 4 5 Administration of PALS protocols & medications 0 1 2 3 4 5 Use of Broslow system 0 1 2 3 4 5 Cogenital heart defects 0 1 2 3 4 5 Congestive heart failure 0 1 2 3 4 5 Post cardiac cath 0 1 2 3 4 5 Post cardiac surgery 0 1 2 3 4 5 Cardiomyopathy 0 1 2 3 4 5 Pericarditis 0 1 2 3 4 5 Shock 0 1 2 3 4 5 Rheumatic fever 0 1 2 3 4 5 Heart transplant 0 1 2 3 4 5 Bacterial endocarditis 0 1 2 3 4 5 Antidysrythmics 0 1 2 3 4 5 Antihypertensives 0 1 2 3 4 5 Cardiac glycoside (digoxin) 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0048 Pediatric 2 of 7
1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Pulmonary Respiratory assessment 0 1 2 3 4 5 Rate & work of breathing 0 1 2 3 4 5 Oral/nasal suctioning 0 1 2 3 4 5 Tracheostomy care and suctioning 0 1 2 3 4 5 Chest Physiotherapy (CPT) 0 1 2 3 4 5 Pulse oximeter 0 1 2 3 4 5 Ventilator management 0 1 2 3 4 5 O2 (NC/mask/oxyhood) 0 1 2 3 4 5 Assist with chest tube insertion & management 0 1 2 3 4 5 Asthma 0 1 2 3 4 5 RSV (Respiratory Syncytial Virus) 0 1 2 3 4 5 Bronchopulmonary Dysplasia (BPD) 0 1 2 3 4 5 Cystic fibrosis 0 1 2 3 4 5 Croup 0 1 2 3 4 5 Pneumonia 0 1 2 3 4 5 Epiglottitis 0 1 2 3 4 5 Tuberculosis 0 1 2 3 4 5 Alupent 0 1 2 3 4 5 Aminophylline (obsolete medication) 0 1 2 3 4 5 Ventolin 0 1 2 3 4 5 Inhaled corticosteroids 0 1 2 3 4 5 Respigam/synergis 0 1 2 3 4 5 Neurological Pediatric neurological assessment 0 1 2 3 4 5 Assist with lumbar puncture 0 1 2 3 4 5 ICP monitoring 0 1 2 3 4 5 Battered child syndrome 0 1 2 3 4 5 Depression 0 1 2 3 4 5 TBI (Traumatic Brain Injury) 0 1 2 3 4 5 Encephalitis 0 1 2 3 4 5 Meningitis 0 1 2 3 4 5 Neuromuscular disease 0 1 2 3 4 5 Spinal cord injury 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0048 Pediatric 3 of 7
1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Neurological - cont. Seizures 0 1 2 3 4 5 Hydrocephalus 0 1 2 3 4 5 VP shunt 0 1 2 3 4 5 Epilepsy 0 1 2 3 4 5 Near drowning 0 1 2 3 4 5 Stimulants (Ritalin, Adderall) 0 1 2 3 4 5 Steroids (Decadron, Solu-Medrol) 0 1 2 3 4 5 Anticonvulsants (Dilantin, phenobarbital) 0 1 2 3 4 5 Orthopedics Assessment of circulation checks 0 1 2 3 4 5 Devised traction (splints, casts, braces) 0 1 2 3 4 5 Pinned traction 0 1 2 3 4 5 Osteomylitis 0 1 2 3 4 5 Fractures 0 1 2 3 4 5 Post Harrington rod insertion 0 1 2 3 4 5 Gastrointestinal GI assessment 0 1 2 3 4 5 Abdominal girth measurement 0 1 2 3 4 5 Feedings 0 1 2 3 4 5 Bottle 0 1 2 3 4 5 Breast 0 1 2 3 4 5 Gavage 0 1 2 3 4 5 Gastrostomy 0 1 2 3 4 5 Nasojejunal 0 1 2 3 4 5 Nasogastric and sump tubes to suction 0 1 2 3 4 5 Placement of oro/nasogastric tubes 0 1 2 3 4 5 Colostomy/ileostomy care 0 1 2 3 4 5 Anorexia/bulimia 0 1 2 3 4 5 Tracheoesophageal Fistula (TEF) 0 1 2 3 4 5 Gastroschisis/omphalocele 0 1 2 3 4 5 Necrotizing Enterocolitis (NEC) 0 1 2 3 4 5 Crohn s disease 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0048 Pediatric 4 of 7
1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Gastrointestinal - cont. Cleft lip/palate 0 1 2 3 4 5 Gastroenteritis 0 1 2 3 4 5 Pyloric stenosis 0 1 2 3 4 5 Ulcerative colitis 0 1 2 3 4 5 GE reflux 0 1 2 3 4 5 GI bleeding 0 1 2 3 4 5 Intestinal parasites 0 1 2 3 4 5 Small bowel transplant 0 1 2 3 4 5 Surgical abdomen 0 1 2 3 4 5 Renal/GU Assessment of fluid balance 0 1 2 3 4 5 Assist with suprapubic tap 0 1 2 3 4 5 Peritoneal dialysis 0 1 2 3 4 5 Insertion & care of Foley catheter 0 1 2 3 4 5 Glomerular nephritits 0 1 2 3 4 5 Ilial conduit ureteral 0 1 2 3 4 5 Nephrotic syndrome 0 1 2 3 4 5 Wilm s tumor 0 1 2 3 4 5 UTI 0 1 2 3 4 5 Hemolytic uremic syndrome 0 1 2 3 4 5 Kidney transplant 0 1 2 3 4 5 Endocrine System Onset diabetes 0 1 2 3 4 5 Diabetic ketoacidosis 0 1 2 3 4 5 Adrenal disorders 0 1 2 3 4 5 Cushing s syndrome 0 1 2 3 4 5 Pituitary disorders 0 1 2 3 4 5 Pancreas transplant 0 1 2 3 4 5 Thyroid malfunction 0 1 2 3 4 5 Insulin administration 0 1 2 3 4 5 Insulin pumps 0 1 2 3 4 5 Thyroid 0 1 2 3 4 5 Growth hormone 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0048 Pediatric 5 of 7
1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Hematology/Oncology Assist with bone marrow aspiration 0 1 2 3 4 5 Anemia 0 1 2 3 4 5 Bone marrow transplant 0 1 2 3 4 5 Leukemia 0 1 2 3 4 5 Sickle cell disease 0 1 2 3 4 5 Hemophilia 0 1 2 3 4 5 Malignant tumors 0 1 2 3 4 5 Spleen trauma/spleenectomy 0 1 2 3 4 5 Neutropenic fever 0 1 2 3 4 5 Sepsis 0 1 2 3 4 5 Hodgkin s 0 1 2 3 4 5 Infectious Diseases Common childhood communicable diseases 0 1 2 3 4 5 HIV/CMV/AIDS 0 1 2 3 4 5 Hepatitis 0 1 2 3 4 5 Kawasaki disease 0 1 2 3 4 5 Age Specific Competencies Newborn/neonate (birth-30 days) 0 1 2 3 4 5 Infants (31 days-1 year) 0 1 2 3 4 5 Toddler (ages 2-3 years) 0 1 2 3 4 5 Preschool (ages 4-5 years) 0 1 2 3 4 5 School age (ages 6-12 years) 0 1 2 3 4 5 Adolescent (ages 13-21 years) 0 1 2 3 4 5 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0048 Pediatric 6 of 7
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: 1. 2. 3. 4. Additional training: 1. 2. 3. 4. Additional equipment: 1. 2. 3. 4. Fax to: 1-888-298-3146 The information on this and all preceding pages is true and correct. Signature Date 2012 Cross Country Healthcare, Inc. Rev. 09/12 F0048 Pediatric 7 of 7