| General Patient Care | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Admission | |||||
| Advanced Directives | |||||
| Charge Nurse Experience | |||||
| Collect Appropriate Data | |||||
| Discharge Teaching | |||||
| Organ/Tissue Donation | |||||
| Patient and Family Teaching | |||||
| Preoperative Teaching | |||||
| Computerized Documentation | 
| Cardiac | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Abnormal Heart Sounds/Murmurs | |||||
| Apical Pulse | |||||
| Auscultation (Rate/Rhythm) | |||||
| Capillary Refill | |||||
| Color | |||||
| Pulses/Circulation Checks | |||||
| Abdominal Aortic Aneurysm | |||||
| Acute MI | |||||
| Angina | |||||
| Cardiac Tamponade | |||||
| Cardiac Teaching | |||||
| Cardiomyopathy | |||||
| Cardiopulmonary Arrest | |||||
| Carotid Endarterectomy | |||||
| Congestive Heart Failure | |||||
| Endocarditis | |||||
| EP Study & Ablation | |||||
| Femoral Popliteal Bypass | |||||
| Heart Transplant | |||||
| Hypertension | |||||
| Hypovolemic Shock | |||||
| Multi-System Organ Failure | |||||
| Myocardial Contusion | |||||
| Pacemaker-External | |||||
| Pacemaker-Permanent | |||||
| Pacemaker-Temporary | |||||
| Pacemaker-Transthoracic (Epicardial) | |||||
| Pericarditis | |||||
| Post AICD Insertion | |||||
| Pre/Post Cardiac Cath | |||||
| Pre/Post Cardiac Surgery | |||||
| Pre/Post PTCA/Stents | |||||
| Valve Replacement | |||||
| Monitoring | |||||
| Ventricular Assist Device (RVAD or LVAD) | 
| Neurological | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Glasgow Coma Scale | |||||
| Level of Consciousness | |||||
| Reflex/Motor Deficits | |||||
| Visual/Communication Deficits | |||||
| Acute Head Injury | |||||
| Alzheimer’s Disease | |||||
| CNS Infection | |||||
| Coma | |||||
| CVA | |||||
| DTS | |||||
| Encephalitis | |||||
| Halo Traction/Cervical Tongs | |||||
| Increased ICP | |||||
| Intracranial Hemorrhage | |||||
| Laminectomy | |||||
| Meningitis | |||||
| Metastatic Tumor | |||||
| Multiple Sclerosis | |||||
| Neuromuscular Disease | |||||
| Pre/Post Neuro Surgery | |||||
| Seizure Disorder | |||||
| Spinal Cord Injury | |||||
| TIAs | |||||
| Tumor Resection | |||||
| Ventriculostomy | 
| Renal/Genitourinary | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Skin Tugor | |||||
| Acute Renal Failure | |||||
| End Stage Renal Disease | |||||
| Hemodialysis | |||||
| Nephrectomy | |||||
| Nephrostomy Tube | |||||
| Peritoneal Dialysis | |||||
| Renal Transplant | |||||
| Suprapubic Cath | |||||
| V Fistula/Shunt | |||||
| Fluid Balance Monitoring | |||||
| Measurement I & O Monitoring | |||||
| BUN & Creatinine Lab | |||||
| Serum Electrolytes Lab | 
| Endocrine/Metabolic | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Diabetic | |||||
| Diabetic Ketoacidosis | |||||
| Drug Overdose | |||||
| Insulin Shock | |||||
| Blood Glucose Lab | |||||
| Thyroid Studies Lab | 
| Musculoskeletal | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Cast Care | |||||
| Circulation/Pulse Checks | |||||
| Amputation | |||||
| External Fixation | |||||
| Joint Replacements | |||||
| Multiple Trauma | |||||
| Paraplegia | |||||
| Rheumatoid Arthritic Disease | 
| Wounds/Integument | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| S/S Infection Assessment | |||||
| Skin Assessment | |||||
| Burns | |||||
| Staged Decubitus Ulcers | |||||
| Stasis Ulcers | |||||
| Surgical Wounds with Drains | |||||
| Skin Breakdown Monitoring | 
| IV Therapy | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Assess/Maintain IV Insertion Site | |||||
| PICC Lines | |||||
| Inserting IVs | |||||
| Multi-Lumen Central Venous Catheters | 
| Blood | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Administer Blood/Blood Products | |||||
| Albumin | 
| Oxygen Administration | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Ambu-Bag | |||||
| Nasal Cannula | |||||
| Nebulizer Treatments | |||||
| Non-Rebreather Mask | |||||
| Portable Oxygen | |||||
| Tracheostomy Tube | |||||
| Venti Mask | 
| Pain Management | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| Assess Pain Level/Tolerance | |||||
| Epidural Anesthesia/Analgesia | |||||
| Moderate Sedation | |||||
| Patient Controlled Analgesia | |||||
| Ramsey Scale | 
| Assisting with | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| 1. Bedside Invasive Procedures | |||||
| 2. Bronchoscopy | |||||
| 3. Cardioversion/Defibrillation | |||||
| 4. Central Line Insertion | |||||
| 5. Chest Tube Insertion | |||||
| 6. Chest Tube Removal | |||||
| 7. Emergency Tracheostomy | |||||
| 8. ET Intubation and Extubation | |||||
| 9. Lumbar Puncture | |||||
| 10. Open Chest Emergency | |||||
| 11. Pericardiocentesis | |||||
| 12. Paracentesis | |||||
| 13. Temporary Pacemaker Insertion | |||||
| 14. Thoracentesis | |||||
| 15. Transesophogeal Echocardiogram | 
| EMR Systems | Rating Stars (Click) | 1 | 2 | 3 | 4 | 
|---|---|---|---|---|---|
| AllScripts | |||||
| ARIA | |||||
| Canopy | |||||
| Epic | |||||
| Cerner | |||||
| Eclipsys | |||||
| McKesson | |||||
| Meditech | |||||
| Other Computerized System | |||||
| Computerized Physician Order Entry | |||||
| EMR Conversion | |||||
| Bar Coding for Medication Administration |