Nurse Practitioner

Information

Name *

Last 4 digits of SSN *

Phone *

Email *

Proficiency Scale

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

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 *

Experience 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 *

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 *

Viral *

Bacterial (1) *

Bacterial (2) *

Nonbacteria *

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 *

Post Thoracic Surgery *

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 *

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 *

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 *

Contact dermatitis *

Tinea corporis *

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 *

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 *

Scoliosis *

Tendonitis *

Bursitis *

Muscular dystrophy *

Parasitic Infections

Pinworms *

Ascariasis *

Pediculosis *

Genitourinary System

Syphilis *

Chlamydia *

Herpes *

Cystitis *

Pyelonephritis *

Urinary tract infection *

Benign prostatic hypertrophy *

Vulvovaginitis *

Hydrocele *

Gonococcal infections *

Prostatitis *

Catheter Care *

Incontinence care-bowel *

Dermal ulcers *

Urine collection *

Nervous System

Vasovagal syncope *

Migraine headaches *

Multiple sclerosis *

Headaches *

Head injury *

Tension *

Anxiety *

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 *

Knowledge of pharmacology *

Knowledge of pharmacokinetics *

Knowledge of drug interactions *

Knowledge of side effects *

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 *

Discharge planning / collaboration *

Suturing *

Cell biopsy *

Starting IV *

Casting and splinting *

Radiographic interpretation (initial) *

Informed consent *

Explanation to patient/family *

Documentation *

Ultrasounds *

Venipuncture *

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) *

Young adult (ages 22-39 years) *

Adults (ages 40-64 years) *

Elderly (ages 80+ years) *

Older adult (ages 65-79 years) *