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CERTIFIED REGISTERED NURSE ANESTHETIST SKILLS CHECKLIST
 
The following checklist is used to assess your experience and skills in order to assist us in placing you in a successful assignment. Please provide an accurate self-assessment of your skills using the following guidelines:
Frequency
Experience
  1. Never Done or Observed Only
  2. Rarely Done (less than 6 times/year)
  3. Occasionally Done (1-2 times/month)
  4. Frequently Done (daily or weekly)
  1. No Experience
  2. Limited Experience
  3. Experienced
  4. Highly Skilled
 
Contact Information      
Name:
Home Phone:
Cell Phone:
Email:
 
Frequency
Experience
Procedures
1
2
3
4
1
2
3
4
Angina  
ENT  
Neurosurgical  
Obstetrics  
Open Heart  
Orthopedics  
Plastics  
Trauma  
Vascular  
Other:  
                   
Medications                  
Accessory Medications  
Adjuvant Medications  
Blood Products  
Fluids  
Ketamine  
Methohexital  
Nitrous Oxide  
Sodium Thiopental  
Valium  
Versed  
Other:  
                   
Airway Management
1
2
3
4
1
2
3
4
Cardiovascular Status  
COPA  
Endotracheal Intubation  
Fiber Optic Intubation  
Nasal Intubation  
Neuromuscular Status and Function  
Oxygentation  
Patient Positioning  
Ventilation  
Other:  
                   
Anesthesia Care
1
2
3
4
1
2
3
4
Infection Control Practices  
Interpretation of Lab Studies  
IV General Anesthesia  

IV Maintenance

  

Mask Induction and Maintenance

  

Total IV Anesthesia

  
Local  

Caudal

  

Epidural

  

Subarachnoid Block

  
Nerve Block  

Intercostal Block

  

Intravenous Regional

  

Local Infiltration Block

  

Major

  

Periocular

  

Plexus

  

Retrobulbar

  

Transtracheal Block

  

Other:

 
Obtaining Accurate Pre-anesthesia Assessment  
Recommend Appropriate Diagnostic Studies  
                   
Work Settings
1
2
3
4
1
2
3
4
Acute Care Hospital  
Dentist Office  
Outpatient Surgery Center  
Plastic Surgery Center  
Private Practice Office Setting  
Other:  
                   
Age
1
2
3
4
1
2
3
4
Newborn (birth - 30 days)  
Infant (30 days - 1 year)  
Toddler (1 - 3 years)  
Preschooler (3 - 5 years)  
School Age (5 - 12 years)  
Adolescents (12 - 18 years)  
Young Adults (18 - 39 years)  
Middle Adults (39 - 64 years)  
Older Adults (64+ years)  
                   
Additional Skills, Training, or Equipment                  
 

The information I have given is true and accurate to the best of my knowledge, and I hereby authorize Next Medical Staffing to release this Skills Checklist and any supporting information to staffing clients of Next Medical Staffing.
                 

 

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