NEXT MEDICAL STAFFING | Physician ER Skills Checklist

ER 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

Never Done or Observed Only
Rarely Done (less than 6 times/year)
Occasionally Done (1-2 times/month)
Frequently Done (daily or weekly)

No Experience
Limited Experience
Experienced
Highly Skilled

Contact Information

Name:
Home Phone:
Cell Phone:
Email:

Frequency

Experience

Scope of Practice

Level I trauma setting

Level II trauma setting

Level III trauma setting

Cardiac arrest/failure

Respiratory arrest/failure

Sepsis

Metabolic disorders including DKA

Acute GI bleeding

Stabilization and initial treatment of OB emergencies including:

Precipitous delivery

Hemorrhage

Ectopic pregnancy

Spontaneous incomplete abortion

Stabilization and initial treatment of single or multiple traumas including:

Blunt or penetrating injuries of the head

Blunt or penetrating injuries of the chest

Blunt or penetrating injuries of the abdomen

Spinal cord injuries

Drowning

Soft tissue injuries including:

The eyes

Fractures

Dislocations

Management and treatment of psychiatric emergencies including:

Acute psychosis

Overdose

Management and treatment of thermal injuries including:

Burns

Electrocution

Hypo/hyperthermia

Management and treatment of pediatric emergencies-not listed above

Clinical Certifications

ACLS	Yes No	Exp. Date	ABLS	Yes No	Exp. Date
ATLS	Yes No	Exp. Date	BLS	Yes No	Exp. Date
NRP	Yes No	Exp. Date	PALS	Yes No	Exp. Date

Board standing in emergency medicine, if applicable:

ABEM Certified: Yes No	Date first Certified:	Date most recently certified
ABEM Qualified: Yes No	Date first qualified:
Expected date of completeion:	Written:	Oral:

AOBEM Certified: Yes No	Date first Certified:	Date most recently certified
AOBEM Qualified: Yes No	Date first qualified:
Expected date of completeion:	Written:	Oral:
Other Boards(please explain):

What formal emergency training or related CME have you completed?
Description of Training
Date from/thru

In a clinical emergency, it is expected that a practitioner will render whatever care they deem necessary to save a life, organ or limb in accordance with sound professional practices.

Please be aware that this form constitutes your application to be credentialed for specific areas and procedures while on assignment through Next Medical Staffing. The credentialing Committee may not consider for approval clinical capabilities where a box is not checked.

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 Clinical Capabilities Checklist and related documents to staffing clients of Next Medical Staffing.

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