Ambulatory Care Skills Checklist

General Patient Care Proficiency Frequency

Admit and AssessPatients

1

2

3

4

1

2

3

4

Advance Directives

1

2

3

4

1

2

3

4

Collect AppropriateData

1

2

3

4

1

2

3

4

Discharge Teaching

1

2

3

4

1

2

3

4

Preoperative Teaching

1

2

3

4

1

2

3

4

Patient Prep

1

2

3

4

1

2

3

4

Computerized Documentation

1

2

3

4

1

2

3

4

Cardiovascular

Assess Heart Tones

1

2

3

4

1

2

3

4

Bedside Tele Monitoring

1

2

3

4

1

2

3

4

Interpretation ofCoagulation Studies

1

2

3

4

1

2

3

4

Perform Pulses/Circulation Checks

1

2

3

4

1

2

3

4

Pre/Post Op CarePacemaker

1

2

3

4

1

2

3

4

Pulmonary

Assess Breath Sounds

1

2

3

4

1

2

3

4

Apply Oxygen

1

2

3

4

1

2

3

4

Interpret ABGs

1

2

3

4

1

2

3

4

Thoracentesis

1

2

3

4

1

2

3

4

Oximetry

1

2

3

4

1

2

3

4

Neurology

Assess NeurologicalSounds

1

2

3

4

1

2

3

4

Epidurals

1

2

3

4

1

2

3

4

Selective Nerve RootBlocks

1

2

3

4

1

2

3

4

Level of Consciousness

1

2

3

4

1

2

3

4

GI

Insertion/Monitoring NG Tubes

1

2

3

4

1

2

3

4

Assessment/Patient Care

1

2

3

4

1

2

3

4

Flexible Sigmoidoscopy

1

2

3

4

1

2

3

4

Hemorrhoid Banding

1

2

3

4

1

2

3

4

Liver Biopsy

1

2

3

4

1

2

3

4

Paracentesis

1

2

3

4

1

2

3

4

Lap Band Surgery

1

2

3

4

1

2

3

4

GU

Bladder Biopsy

1

2

3

4

1

2

3

4

Cystoscopy

1

2

3

4

1

2

3

4

Urethral Dilation

1

2

3

4

1

2

3

4

Nephrostomy

1

2

3

4

1

2

3

4

Kidney Biopsy

1

2

3

4

1

2

3

4

Suprapubic Catheter

1

2

3

4

1

2

3

4

Prostrate Biopsy

1

2

3

4

1

2

3

4

Endocrine

Care of Diabetic Patient

1

2

3

4

1

2

3

4

Diabetic Teaching

1

2

3

4

1

2

3

4

ENT and Mouth

Prosthodontics –Restorative Dentistry

1

2

3

4

1

2

3

4

Mouth Biopsy

1

2

3

4

1

2

3

4

Myringotomy

1

2

3

4

1

2

3

4

Maxillofacial Prosthetics

1

2

3

4

1

2

3

4

Nose Biopsy

1

2

3

4

1

2

3

4

Thyroid Aspirate Biopsy

1

2

3

4

1

2

3

4

Fiberoptic Laryngoscopy

1

2

3

4

1

2

3

4

Tonsillectomy

1

2

3

4

1

2

3

4

Rhinoplasty

1

2

3

4

1

2

3

4

Wounds/Integument

Application of Burn Dressings

1

2

3

4

1

2

3

4

Application of Dressings

1

2

3

4

1

2

3

4

Debridement of Wonund

1

2

3

4

1

2

3

4

Wound Care

1

2

3

4

1

2

3

4

OB/GYN

Electrodessication and Curettage (ED&C)

1

2

3

4

1

2

3

4

Nipple Reconstruction

1

2

3

4

1

2

3

4

Musculoskeletal

Arthrocentesis

1

2

3

4

1

2

3

4

External Hardware andPin Care

1

2

3

4

1

2

3

4

Arthroscopy

1

2

3

4

1

2

3

4

Open Reduction and Internal Fixation

1

2

3

4

1

2

3

4

Closed Reduction and Internal Fixation

1

2

3

4

1

2

3

4

Trigger Point Injections

1

2

3

4

1

2

3

4

Plastics

Liposuction

1

2

3

4

1

2

3

4

Plastic Surgery

1

2

3

4

1

2

3

4

Cosmetic

1

2

3

4

1

2

3

4

Age Group Experience

0 - 30 Days

1

2

3

4

1

2

3

4

30 Days - 1 Year

1

2

3

4

1

2

3

4

1 - 3 Years

1

2

3

4

1

2

3

4

3 - 5 Years

1

2

3

4

1

2

3

4

5 - 12 Years

1

2

3

4

1

2

3

4

12 - 18 Years

1

2

3

4

1

2

3

4

18 - 39 Years

1

2

3

4

1

2

3

4

39 - 64 Years

1

2

3

4

1

2

3

4

64+ Years

1

2

3

4

1

2

3

4

General Medications/Therapeutic Interventions

Administer IM and SQMeds

1

2

3

4

1

2

3

4

Administer Inhalation Medications

1

2

3

4

1

2

3

4

Administer POMedications

1

2

3

4

1

2

3

4

Bladder Irrigation and Instillation

1

2

3

4

1

2

3

4

Needless Systems

1

2

3

4

1

2

3

4

Chemotherapy

1

2

3

4

1

2

3

4

EMR

Epic

1

2

3

4

1

2

3

4

Cerner

1

2

3

4

1

2

3

4

Eclipsys

1

2

3

4

1

2

3

4

McKesson

1

2

3

4

1

2

3

4

Meditech

1

2

3

4

1

2

3

4

Other Computerized System

1

2

3

4

1

2

3

4

Computerized Physician Order Entry

1

2

3

4

1

2

3

4

Bar Coding for Medication Administration

1

2

3

4

1

2

3

4

Do you speak any languages other than English?

Yes

No

If yes, which language(s)?

*

I hereby certify that ALL information I have provided to Clover Health Services, on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Proficiency : -	1 = Never Performanced	2 = Limited Experience	3 = Comfortable Performing	4 = Proficient
Frequency : -	1 = Never	2 = Sometimes	3 = Often	4 = Always