PT/PTA

This checklist was electronically signed on (Today’s date)

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency Scale:

1 . No Experience

2 . Need Training

3 . Able to perform with supervision

4 . Able to perform independently

ADULT

Sports Medicine

Procedures / Treatments:

Other

AGE SPECIFIC COMPETENCIES

CERTIFICATIONS

BLS	Yes	No
CNRN	Yes	No
ACLS	Yes	No
CCRN	Yes	No
Other:

I hereby certify that ALL information I have provided 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.

Neck Injuries / Surgeries
Back Injuries / Surgeries
Hip Fractures / Injuries
Total Hip Replacement
Knee Injuries
Total Knee Replacement
Upper Extrem Joint Replacements
Shoulder Injuries
Degen. Joint Disease / Arthritis
Hand Injuries
Temporomandibular Joint (TMJ)
Post Operative Care
Amputations
Stroke Rehabilitation
Cognitive Disorders
Head Trauma
Spinal Cord Injury
Functional Splinting
Adaptive Equipment-Wheelchair
Neuromuscular Diseases
Multiple Sclerosis
Upper Extremity Prosthetics
Above Knee Prosthetics
Below Knee Prosthetics

LIDO
Nautilus / Eagle
Taping
Other
Chest PT
Cardiac Rehab
ICU Procedures
CCU Procedures
SICU Procedures
Burn Management
Work Hardening - Work Site Eval
Work Capacity Eval

Ankle / Foot Orthosis
Slings
Splints - Wrist / Hand
CPM Machine
Hydrotherapy
Whirlpool
Hubbard Tank
Therapeutic Pool
TENS
Electrical Stimulation
Ultrasound
Cryotherapy
Massage
Diathermy
Acupressure
Spinal Mobilization
Extremity Mobilization
Myofacial Release
Craniosacral Techniques
Cervical Traction
Lumbar Traction
Activities of Daily Living
Gait Training
transfers
Sports Medecine
Athletic Injuries
Biodex
Cybex
Orthotron

Functional Capacity Eval
Muscle Energy Techniques
Activities of Daily Living
Universal Precautions
Skilled Nursing Documentation
Medicare A
Medicare B
State Healthcare
Skilled Nursing Documentation

Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)
Elderly (ages 80+ years)