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PHYSICIANS

ADVANCED PRACTICE

PHARMACY

THERAPY

RADIATION ONCOLOGY

LABORATORY

IMAGING

RESPIRATORY

EMPLOYERS
 
URGENT CARE 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
AREAS OF PRACTICE
1
2
3
4
1
2
3
4
Acute Ambulatory Care/Urgent Care  
HMO/managed care  
Hospitalist  
ICU/CCU  
Inpatient Medicine  
Outpatient Medicine  
Rural Medicine  
                   
GYN
1
2
3
4
1
2
3
4
Colposcopy  
D&C  
Endometrial biopsy  
IUD insertion and removal  
Pelvic exam / pap smear  
                   
MEDICINE
1
2
3
4
1
2
3
4
Adult outpatient  
Adult Inpatient:  

With ICU/CCU

  

Without ICU/CCU

  
                   
OB
1
2
3
4
1
2
3
4
Prenatal Care  
Date of Last Delivery:                  
**Physicians who recently completed residency must provide the last 36 months Within last 12 months Last 12-24 months Last 24-36 months
C-sections # # #
Instrument assisted deliveries (forceps, vacuum, etc): # # #
Ultrasounds: # # #
VBAC: # # #
Vaginal Deliveries # # #
                   
OCCUPATIONAL MEDICINE
1
2
3
4
1
2
3
4
Diagnosis and management of common industrial-related medical problems  
Disability exams  
Employment Physicals  
                   
ORTHOPEDIC
1
2
3
4
1
2
3
4
Non-displaced fractures  
Trigger Point / Joint Injections  
                   
PEDIATRIC
1
2
3
4
1
2
3
4
General inpatient  
General outpatient  
Newborn Care  
Newborn resuscitation  
                   
PROCEDURES
1
2
3
4
1
2
3
4
Ventilation management* #                  
Evaluation and management of acute volume / BP issues
Insertion of:                  
Arterial Line #                  
Central Line #                  
EKG Interpretation (Unofficial) #                  
PA Catheter #                  
Diagnostic / therapeutic taps:                  
Lumbar puncture                  
Paracentesis #                  
Thoracentesis #                  
*Ventilation management-establishing and maintaining an airway; various modes of ventilation for up to 24 hours without
pulmonary consultation		                  
                   
PSYCHIATRIC
1
2
3
4
1
2
3
4
Uncomplicated adult  
Uncomplicated child/adolescent  
Uncomplicated geriatric  
                   
SURGERY
1
2
3
4
1
2
3
4
I & D (incision and drainage)  
Skin/tissue biopsy  
Surgical assisting  
Suturing of minor lacerations  
                   
CLINICAL CERTIFICATIONS
1
2
3
4
1
2
3
4
ACLS 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
 
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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