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INTERNAL MEDICINE 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
Settings
1
2
3
4
1
2
3
4
Inpatient/Hospital Based  
Outpatient/Office Based  
Other:  
                   
Specific Procedures
1
2
3
4
1
2
3
4
Arterial Puncture  
Bone Marrow Needle Aspiration  
Bone Marrow Needle Biopsy  
Cardiopulmonary Resuscitation  
ECG Interpretation  
Endotracheal Intubation (Emergency)  
Gastrointestinal Tract Intubation  
Lumbar Puncture  
Needle Aspiration of Joint  
Needle Injection of Bursa & Joint  
Paracentesis  
Parietal Pleura 1 Biopsy  
Percutaneous Needle Aspiration of Liver  
Pericardiocentesis  
Peritoneal Biopsy  
Phlebotomy  
Placement of Venous Catheters  
Proctosigmoidoscopy with Biopsy  
Skin Biopsy  
Suprapubic Bladder Aspiration  
Thoracentesis  
Tracheostomy (Emergency)  
Transtracheal Aspiration  
Urinary Bladder Catheterization  
Venous Cutdown  
                   
Arthritis
1
2
3
4
1
2
3
4
Percutaneous Needle Biopsy of Synovial Membrane  
Other:  
                   
Cardiology
1
2
3
4
1
2
3
4
Echocardiography  
Exercise Electrocardiography  
Phonocardiography  
Placement of Arterial Catheter  
                   
Cardiac Catheterization Procedures
1
2
3
4
1
2
3
4
Coronary Arteries  
D.C. Cardioversion  
Left Heart  
Placement of Transvenous Pacing Electrodes  
Right Heart  
Swan-Ganz  
                   
Gastroenterology
1
2
3
4
1
2
3
4
Ambulatory pH Testing  
Anorectal Motility Testing  
Biofeedback  
Breath Testing  
Capsule Endoscopy Examination  
Colonoscopy With or Without Therapeutics  
Endoanal Ultrasound Examination  
Endoluminal Endoscopic Stent Placement  
Endoscopic Retrograde Cholangiopancreatography With or Without Therapeutics  
Endoscopic Ultrasound Examination With or Without Fine Needle Aspiration  
Esophageal Motility Testing  
Esophagogastroduodenoscopy With or Without Therapeutics  
Flexible Sigmoidoscopy With or Without Therapeutics  
Gastrointestinal Intubation and Aspiration With or Without Fluoroscopy  
Hollander (Insulin) Test of Gastric Secretion With Intubation, Fluoroscopic Placement, Injection Sampling and Interpretation  
Injection Procedure for Percutaneous Transhepatic Cholangiography  
Liver Biopsy With or Without Ultrasound Guidance  
Percutaneous Endoscopic Gatrostomy  
Push Enteroscopy With or Without Therapeutics  
Secretin Test of Pancreatic Function With Intubation, Fluoroscopic Placement, Skin Testing, Injections  
Other:  
                   
Hematolgoy/Oncology
1
2
3
4
1
2
3
4
Bone Marrow Needle Aspiration or Biopsy With Interpretation  
Neoplastic Chemotherapy, Oral Crinfusion  
Neoplastic Chemotherapy, Oral Crinfusion  
Other:  
                   
Infectious Disease
1
2
3
4
1
2
3
4
Antibiotic Tube Dilution & Interpretation  
Determination of Serum Cidal Levels of Antibiotics  
Percutaneous Needle Aspiration of Lung  
Other:  
                   
Metabolism
1
2
3
4
1
2
3
4
Isotope Administration  
Percutaneous Needle Biopsy of Thyroid  
Other:  
                   
Nephrology
1
2
3
4
1
2
3
4
Hemodialysis  
Percutaneous Needle Bx of Kidney  
Peritoneal Dialysis  
Stamey Test  
Other:  
                   
Pulmonary
1
2
3
4
1
2
3
4
100% Oxygen Studies for Pulmonary A-V Shunt  
Fiberoptic Bronchoscopy With or Without Biopsy  
Percutaneous Needle Aspiration and/or Biopsy of Lung  
Percutaneous Needle Biopsy of Pleura  
Pulmonary Function Testing & Interpretation  
Regional Ventilation/Perfusion With Xenon 133  
Respiratory Center Sensitivity Studies  
Respiratory Therapy  
Other:  
                   
Populations
1
2
3
4
1
2
3
4
Adult  
Neonate  
 
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 Skills Checklist and any supporting information to staffing clients of Next Medical Staffing.
                 

 

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