Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
ASSESSMENT
Admission 0 1 2
Initial nursing assessment & care plan 0 1 2
Initial treatment plan 0 1 2
Neurological vital signs 0 1 2
Nursing diagnoses 0 1 2
Nursing reassessment & care planning
update 0 1 2
Suicide risk assessment 0 1 2
EQUIPMENT & PROCEDURES
Active participation in
multi-disciplinary staffing 0 1 2
Assist in administration of ECT 0 1 2
Assist with lumbar puncture 0 1 2
Cardiopulmonary resuscitation 0 1 2
Charge nurse experience 0 1 2
Charting-Behavioristic 0 1 2
Charting-Treatment/goal-oriented 0 1 2
Discharge planning 0 1 2
Electroconvulsive therapy 0 1 2
Group therapy leader 0 1 2
Insertion & care of straight Foley Catheter
Female 0 1 2
Male 0 1 2
Management of drug/alcohol detox
symptoms 0 1 2
Management of assaultive behavior 0 1 2
Multi-disciplinary treatment
team participation 0 1 2
O2 therapy & medication delivery system 0 1 2
Bag & Mask 0 1 2
External CPAP 0 1 2
Face masks 0 1 2
Inhalers 0 1 2
Nasal cannula 0 1 2
Portable O2 tank 0 1 2
Trach collar 0 1 2
Oro-naso-pharynx suctioning 0 1 2
Participation in milieu therapy 0 1 2
Patient teaching 0 1 2
Psychiatric emergency response team 0 1 2
Psychiatric home health 0 1 2
Rapid tranquilization 0 1 2
Telephone crisis intervention 0 1 2
EQUIPMENT & PROCEDURES
Restraints, application & assessment of: 0 1 2
Ambulatory cuffs 0 1 2
Full restraints 0 1 2
Wrist restraints 0 1 2
Therapeutic communication skills 0 1 2
Tube feeding 0 1 2
CARE OF THE PATIENT WITH:
Alcohol dependency 0 1 2
Drug dependency 0 1 2
Electroconvulsive therapy 0 1 2
Hallucinations 0 1 2
Manic behavior 0 1 2
Med-psych patient 0 1 2
Organic disorder 0 1 2
Partial hospital/intensive outpatient
program 0 1 2
Seclusion & restraints 0 1 2
Suicidal behavior 0 1 2
Tracheostomy 0 1 2
MEDICATION:
Administration of oral psychotropic
medications 0 1 2
Heparin 0 1 2
Intramuscular meds 0 1 2
Management of extrapyramidal
symptoms (EPS) 0 1 2
Oral Adm 0 1 2
Rectal Adm 0 1 2
Sub-q Adm 0 1 2
Unit dose Adm 0 1 2
Z-technique Adm 0 1 2
PHLEBOTOMY/IV THERAPY - Equipment & procedure
Administration of blood/blood products 0 1 2
Drawing blood from central line 0 1 2
Drawing venous blood 0 1 2
Management of patient with
hyperalimentation 0 1 2
Management of patient with IV 0 1 2
Starting IV’s
Angiocath 0 1 2
Butterfly 0 1 2
Heparin lock 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Preschool (4 - 5 Yrs) B=School Age (6 - 12 Yrs) C=Adolescent (13 - 18 Yrs)
D=Young Adult(19-39 Yrs) E= Middle Adult (40-64 Yrs) F=Older Adult (65 + Yrs)
A
B
C
D
E
F
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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