RESPIRATORY 1 2 3 4 P A NEUROLOGY 1 2 3 4 P AAssessment of Breath Sounds Neuro Assessment / Vital SignsAdminister O2 (NC, Mask) Glasgow Coma ScalePulse Oximetry Assist with Lumbar PunctureNebulizer Set-up Identify Neuro ComplicationsRe-breather Mask Seizure PrecautionsVenturi Mask Aneurysm PrecautionsVentilate with Ambu-bag Assist with Intubation Open / Closed Head InjuryRapid Sequence Induction Acute CVACare of Intubated Patient Acute Spinal Cord Injury Suctioning Increased ICP Assist Needle Thoracostomy Halo Traction / Cervical TongsTroubleshoot Ventilator Problems CNS InfectionsDraw Blood from Arterial Line MUSCULOSKELETAL 1 2 3 4 P AInterpret Arterial Blood Gases Immobilization & SplintingAssist with Emergency Trach Ice Bag ApplicationAssist with Emergency Cric Fit / Instruct Crutch WalkingAssist with Thoracentesis Assist w/ Cast ApplicationAssist with Bronchoscopy Cast Removal

Assist w/ External Fixation PinsAsthma Assist w/ Nerve BlocksPulmonary EdemaChest Injury Ace WrapsChest Tubes / Pleurevac Posterior SplintAssess Resp Complications Clavicle Strap

Shoulder ImmobilizerGASTROINTESTINAL 1 2 3 4 P A Knee ImmobilizerAssess Abd & Bowel SoundsIdentification of Abnormalities GENITO-URINARY 1 2 3 4 P AInsert / Maintain NG tubes Insertion of Male CatheterInsert / Maintain EWAL tube Insertion of Female CatheterGastric Lavage Setup / Assist with Vaginal ExamsNG Meds (ie:Activated Charcoal) Assist with Sexual Assault Exams

Evidence Collection / DocumentionDrug Overdose / DTsGastrostomy / Jejunostomy Tube Eval of Abd PainGI Bleed GYN History / Prenatal AssessAcute Pancreatitis Precipitous DeliveryOpen Abd Wound / Incision Spontaneous ABAbdominal Aortic Aneurysm Care of Newborn

Assist with Suction Curettage

Application & Assistance:

Care of Patient With:Knowledge of Procedure:

Indicate Pediatric and / or Adult Experience P = Pediatric Experience A = Adult Experience

Care of Patient With:

EMERGENCY DEPARTMENTSKILLS CHECKLIST

This self evaluation is for assessing your experience in specific clinical areas. This self evaluation will not be a determining factor inaccepting your application to become an employee of Supplemental Health Care.

1 = No Experience 2 = Limited Experience 3 = Experienced 4 = Highly Skilled

Care of Patient With:

Revised 10/2006 © 2006, SHC Services, Inc. Emergency Dept 1 of 3

RENAL 1 2 3 4 P A INFUSION THERAPY 1 2 3 4 P AInfusion Pump

Acute Renal Failure Syringe PumpChronic Renal Failure Blood / Blood Products Admin.Hemodialysis Insert Peripheral IV / HeplockPeritoneal Dialysis Discontinue Peripheral IV / HeplockRenal Transplant

VenipunctureCARDIAC 1 2 3 4 P A Hickman / BroviacAssessment of Heart Sounds GroshongPlace Cardiac Monitor / Telemetry Implanted PortsTroubleshoot Monitor / Telemetry PICC / MidlineIdentify Lethal DysrhythmiasPerform 12-lead EKG CutdownBasic 12-Lead Interpretation Arterial LinesAssist with Arrest / Resusc. Central Venous CatheterDefibrillation / Cardioversion Pulmonary Artery CatheterAutomatic External Defib (AED) External Pacemaker

Temporary Transvenous PacerAngina PericardiocentesisAcute MI Intraosseous InfusionsCongestive Heart Failure AutotransfuserAneurysmPermanent Pacemaker TRAUMA CARE 1 2 3 4 P ATemporary Pacemaker Trauma AssessmentAutomatic Implanted Defibrillator Primary SurveyHeart Transplant Secondary SurveySeptic Shock Trauma ScoreHypovolemic Shock Pediatric Trauma ScoreCardiogenic Shock Principles of Fluid Resuscit.Anaphylactic Shock Principles of C-Spine Immob.

Use of Philadelphia CollarEpinephrine Use of BackboardAtropine Principles of Fluid Resuscit.Bicarbonate Use of Rapid / Pressure InfuserLidocaine Principles of Fluid Resuscit.Streptokinase (Indication / Manage) Gunshot WoundTPA (Indication / Management) Stab Wound

Blunt Chest TraumaBretylium Blunt Abdominal TraumaDopamine MAST SuitInsulin HypothermiaPronestyl Frostbite

INTEGUMENTARY 1 2 3 4 P A Chemical BurnWound Assess & Dressings Electrical BurnWound Cultures Thermal BurnWound IrrigationSuture Setup & Assist Diagnostic Peritoneal LavageLocal Ansesthetics Chest Tube InsertionTetanus Prophylactics ThoracotomyVenomous Bites

EAR-NOSE-THROAT (ENT) 1 2 3 4 P APEDIATRICS 1 2 3 4 P A Eye IrrigationsPrinciples of Growth & Devleopment Ear IrrigationsVital Signs / Normal Values for Age Visual AcuityCare of Febrile Patient Remove Contact LensLegal Principles re: Child Abuse Epistaxis

Care of Patient With:

Assist with:

Care of Patient With:

Assist With Insertion and Setup:

Access / Care / Blood Draws:

Infusion Med Administration:

Emergency Medication Administration:

Care of Patient With:

Revised 10/2006 © 2006, SHC Services, Inc. Emergency Dept 2 of 3

OTHER 1 2 3 4 P A OTHER 1 2 3 4 P AIsolation TechniquesAdvance Directives Psychiatric IssuesPostmortem Care OncologyEmergency Pre-operative Prep ChemotherapyTriage Procedure AIDSAware of COBRA Legislation KetoacidosisAware of Consent Procedures Bone Marrow TransplantCrisis Intervention Liver Transplant

AGE 1 2 3 4 AGE 1 2 3 4Newborn (birth-30 days) Adolescents (12 - 18 years)Infant (30 days - 1 year) Young Adults (18 - 39 years)Toddler (1 - 3 years) Middle Adults (39 - 64 years)Preschooler (3 - 5 years) Older Adults (64+ years)School Age (5 - 12 years)

Applicant Signature Date

Applicant Name & Title (please print)

SHC Representative Signature Date

The information I have given is true and accurate to the best of my knowledge, and I hereby authorizeSupplemental Health Care to release this Skills Checklist to staffing clients of Supplemental Health Care.Submit this skills self evaluation with your initial application. To be updated annually.

Care of Patient With:

Age-Appropriate Nursing Care: Ability to adapt care to incorporate normal growth and development, adapt method and terminology of client instructions as it relates to the age and comprehension level of the client, and to ensure a safe environment - reflecting specific needs of the client and various age groups.

Revised 10/2006 © 2006, SHC Services, Inc. Emergency Dept 3 of 3