pre-employment check list - pulse medical staffing · pre-employment check list ... assist in...
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620 N. Trade Winds Parkway Suite A Columbia, MO 65202 Toll Free Phone & Fax 877.883.8677
Pre-Employment Check List
Please provide clear copies of the following along with your completed application. Please complete our application entirely, incomplete applications will delay
processing.
□ Drivers License □ Social Security Card □ Current Nursing License □ Any Certifications (if applicable) □ Current CPR □ Current ACLS (if applicable) Complete the following forms (included in this application packet).
□ Application □ Reference Check #1 □ Reference Check #2 □ Skills Checklist □ Testing as required □ Health Statement/Physical □ Proof of Vaccination History □ HIPAA Statement □ I-9 Documentation
Post Hire – Check List
□ Federal W-4 □ Missouri W-4 □ Direct Deposit Form □ Payroll Input Form
Thank You for applying with us. Please feel free to call us anytime if you have questions.
1 620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
Name:
Please indicate 1, 2, 3, or 4 in boxes below using the following rankings: 1 = Clinicals Only 2 = Some Experience 3 = Experienced 4 = Can Perform Task Independently
UNIT / SKILLS Exp UNIT / SKILLS Exp
Premature/Newborn/Neonate (birth - 30 days) Young Adults (18 - 39)
Infant (30 days - 1 year) Middle Adults (39 - 64)
Toddler (1 - 3 years) Older Adults (64+)
Preschooler (3 - 5 years) Growth/Developmental Parameters
School Age (5 - 12 years) Family Intervention Skills
Adolescents (12 - 18 years) Death/Dying
NEUROLOGICAL SYSTEMS
Assessing sensory-motor function extremities LOC assessment
Assist with lumbar puncture Monitoring of ICP appropriate interventions for changes in pressure
Cervical traction Pre/Post neuro surgical care Cranial nerve assessment Seizure precautions Crutchfield tongs Use of Glascow coma scale Halo traction Visual acuity measurement
Care of patients with: Multiple Sclerosis
Aphasia Multiple trauma patient
Closed head injury Overdose patient
Craniotomy Seizure disorder
CVA Spinal disorder
CV/CIRCULATORY
Arterial line/Swan Ganz set up Normal physiology of CV system *obtain blood sample from line Post angiogram care *remove arterial line Post open heart care
Assess heart sounds Removal of arterial/venous sheaths
Assist with pacemaker insertion Resuscitation
*temporary/single/double lumen *team member
*recognize pacemaker malfunction *perform defibrillation
*pacemaker care *perform/set up emergency cardioversion *paceport Swan Ganz *prep and administer meds Assist with pericardiocentes Set up, run interpret 12 lead EKG
External pacemaker maintenance SVO2 monitoring
Blood pressure monitoring/automatic machine *interpretation
Assist in *troubleshooting
*arterial line insertion Swan Ganz hemodynamic monitoring knowledge of
*Swan Ganz insertion with/or without fluoroscopy *RA/PAP/PCWP/CO/SVRPVR/CI Dysrhythmia recognition and intervention *troubleshooting waveforms Normal anatomy of heart Use of cardiac monitor
*left side *proper lead placement
*right side
Care of patients with: *septic Acute aneurysm Transplant/cardiac Angina CHF Shock Deep vein thrombosis *cardiogenic Pulmonary edema
*hypovolemic Acute MI
SKILLS CHECKLIST CRITICAL CARE
2 620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
CRITICAL CARE SKILLS CHECKLIST (continued)
UNIT / SKILLS Exp UNIT / SKILLS Exp
PULMONARY
Ambu bag techniques Pulse Oximetry
Administer oxygen Suctioning
Use of apnea monitor *use of emergency equipment
Assess lung sounds Thoracentesis
Assist in intubation/extubation Tracheostomy *oropharyngeal airway *trach tray set up *nasopharyngeal airway *assist with emergency trach Chest physiotherapy *changing of trach or tube *complications of *skin care
Chest tube insertion (assist in) *dressing changes
Inventive spirometer Ventilator management
Nebulizer set up and use *patient assessment
Normal physiology of pulmonary *troubleshooting with vents
*vascular system *weaning from ventilator
Obtain arterial blood gas List types of ventilators used:
*result interpretation 1)
Pavulonized patient 2)
3)
Care of patients with: DIC
Acute respiratory distress Hemothorax
AIDS Pneumonia
Asthma Pulmonary embolism Collapsed lung TB COPD Transplant
CI/CU/REPRODUCTIVE/ENDOCRINE/INTEGRUMENTARY
Administer med via NG/gastrostomy tube Poison control
Assist with vas-cath insertion Wound care irrigations
AV shunt/fistula care Insulin preparation and administration
Catheter insertion *blood glucose monitoring
*female Equipment used
*male *jejunostomy care
Care of burn patient *NG tube insertion/lavage
Dialysis *normal physiology of renal & GI System
*hemo *ostomy/stoma care
*peritoneal *peritoneal lavage
Care of patients with: GI bleed Acute cholecystitis Hyper/hypoglycemia Acute renal failure Multiple abdominal wounds Bowel obstruction Pancreatitis Diabetes Transplant/kidney
IV THERAPY
Administration of chemotherapy meds *caloric and fluid requirements Administration of antibiotic therapy Insertion of central line Administration/mixing of IV meds *CVP tray set up *meds via IV push *use of Broviac & Hickman catheters Administration of continuous fluids *implanted venous access ports Blood/blood product administration/precautions
*dressing changes
3 620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
CRITICAL CARE SKILLS CHECKLIST (continued)
UNIT / SKILLS Exp UNIT / SKILLS Exp
IV THERAPY (continued) Calculate doses Insertion of peripheral line Calculate rates *dressing changes *mcg/min *discontinuing line
*cg/kg/min Pump Operations Hang IV piggy backs *IVAC Hyperalimenation *IMED *peripheral/central line *Other: *knowledge of solutions
MEDICAL ADMINISTRATION
Injections PO administration
*preparation of meds/syringe SL administration
*sit selection (i.e. SQ vs. IM)
Use of the following: KCL
Amiodarone Levophed Atropine Lidocaine Bicarbonate Mannitol Bretylium Magnesium Sulfate Cardizem Metoprolol (Lopressor)
Dextrose Neo-Synephrine
Digitalis Nipride
Dopamine Nitroglycerin
Dobutamine (Dobutrex) Phenobarbital
Digoxin (Lanoxin) Pavulon
Epinephrine Pitressin
Esmolal Prednisone
Heparin Procainamide Inderal Prostoglandins Inocor Reteplase Recombinant (Retavase) Insulin Streptokinase
Isuprel TPA (Alteplase)
PSYCHIATRIC CONSIDERATIONS Psychiatric patient assessment *care of violent patient *care of acute psychotic *administer psychiatric medications
ADDITIONAL NURSING RESPONSIBILITIES
Specimen collection Charge nurse responsibilities
*capillary blood draw Universal isolation procedures/precautions
*sputum Lab value interpretation
*stool Organ procurement
*venipuncture Pain management
*wound culture *use of IV narcotics
Admission Problem oriented medical records
*initial assessment/documentation
Signature:
Date:
The information I have given is true and accurate to the best of my knowledge. I hereby
authorize Pulse Medical Staffing to release this Skills Checklist to facilities/clients of Pulse
Medical Staffing in relation to consideration of my Employment with those facilities/clients.
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
PROFESSIONAL REFERENCE CHECK
I, _________________________________________________________
(Employee Name)
Authorize Pulse Medical Staffing to request any information concerning my qualifications, performance and work ethics. Further I hereby release the company or person completing this form from any and all liability in supplying the requested information.
Signature:
Date:
REFERENCE INFORMATION (Applicant, please complete)
Company: Reference Name:
Position Held: Reference Phone:
Start Date: Reference Address:
End Date: Reason for Leaving:
Applicant – DO NOT WRITE BELOW THIS LINE
---------------------------------------------------------------------------------------------------------------- Would you rehire this person? Yes No If no, please explain: ______________________________________________________________________ Please rate the applicant on a scale from 1 to 10 (10 being the highest):
Attribute/Quality 1 2 3 4 5 6 7 8 9 10 Additional Comments
Dependability
Flexibility
Team Work
Professionalism
Interaction with Co-Workers
Interaction with Supervisors
Joint Commission Compliance
HIPPA Compliance
Policies/Procedures
Appearance
What is your affiliation to the above applicant? Supervisor / Former Supervisor Coworker / Former Coworker
Human Resources Other: ___________________
Completed by:
Signature:
Date:
Title:
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
PROFESSIONAL REFERENCE CHECK
I, _________________________________________________________
(Employee Name)
Authorize Pulse Medical Staffing to request any information concerning my qualifications, performance and work ethics. Further I hereby release the company or person completing this form from any and all liability in supplying the requested information.
Signature:
Date:
REFERENCE INFORMATION (Applicant, please complete)
Company: Reference Name:
Position Held: Reference Phone:
Start Date: Reference Address:
End Date: Reason for Leaving:
Applicant – DO NOT WRITE BELOW THIS LINE
---------------------------------------------------------------------------------------------------------------- Would you rehire this person? Yes No If no, please explain: ______________________________________________________________________ Please rate the applicant on a scale from 1 to 10 (10 being the highest):
Attribute/Quality 1 2 3 4 5 6 7 8 9 10 Additional Comments
Dependability
Flexibility
Team Work
Professionalism
Interaction with Co-Workers
Interaction with Supervisors
Joint Commission Compliance
HIPPA Compliance
Policies/Procedures
Appearance
What is your affiliation to the above applicant? Supervisor / Former Supervisor Coworker / Former Coworker
Human Resources Other: ____________________
Completed by:
Signature:
Date:
Title:
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
Employee Health Statement
Employee Name: __________________________________________________________ Date of Birth: _________________________________
I authorize my healthcare provider to release my health information to Pulse Medical
Staffing. I understand that this information is disseminated to the facilities as part of my
placement as required by facility and JCAHCO.
Employee Signature: _______________________________________________________ Date: _______________________________________
Physician’s Office No. ______________________________________________________ Physician’s Fax No._____________________________
Applicant – DO NOT WRITE BELOW THIS LINE
--------------------------------------------------------------------------------------------------------------------------------------------------------------
The above patient has been seen by me and has been found to be in good mental and
physical health, free of communicable disease, and able to function in the healthcare
profession without any physical limitations.
Today’s Date: ________________________________________
Date of last visit: ______________________________________
Physician’s Printed Name: ___________________________________________________ Physician’s Signature: ______________________________________________
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
Immunization’s Statement
Employee Name: _________________________________________________________ Date of Birth: _________________________________
OSHA requires that all healthcare workers at risk of acquiring the HBV be vaccinated. By signing below
I certify that I have the general education regarding exposure to the blood borne pathogens as
required by OSHA. I further understand that I should follow each facilities training and policy
regarding blood and body fluids.
I hereby verify that these statements are truthful and accurate.
Employee Signature: _______________________________________________________Date: ________________________________________
Hepatitis B
□ I decline the vaccine due to I have received the series.
□ I have completed the vaccine series on the following date: ___________________________
Tuberculosis
Last TB skin test (PPD) Date’s: 1) _______________________ 2) _____________________________
If positive TB skin test (PPD) Date: _________________________________Last chest X-ray Date: __________________________
MMR Vaccination Date’s: 1) ___________________________ 2) _____________________________
If positive/exposed Date: _______________________________
Varicella
Vaccination Date’s: 1) ___________________________ 2) _____________________________
If positive/exposed Date: _______________________________
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
Policy on Confidentiality and Dissemination of Patient Information and Staff Member Verification Given the nature of our work, it is imperative that we maintain the confidence of patient information that we receive in the course or our work. Pulse Medical Staffing prohibits the release of any patient information to anyone outside the department or facility except in limited circumstances and discussions or disclosures of protected health information (PHI) within the organization should be limited to the minimum necessary that is needed for the recipient of the information to perform their job. Acceptable uses of PHI within the organization include but are not limited to peer review, internal audits, quality assurance and billing. I understand Pulse Medical Staffing provides services to area healthcare facilities patients that are private and confidential and that I am a crucial step in respecting the privacy rights of these patients. I understand that it is necessary, in the rendering of Pulse Medical Staffing services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographic and that all such information is strictly confidential and protected by federal and state laws that prohibit its unauthorized use or disclosure. I have received training in the confidentiality policies and procedures set in place by Pulse Medical Staffing, listed in my personnel file and agree I will comply with such policies and procedures during my entire employment with Pulse Medical Staffing. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify Pulse Medical Staffing HIPAA Privacy Officer Liaison immediately. In addition, I understand that breach of patient confidentiality or privacy may result in disciplinary action up to and including suspension or termination of my employment with Pulse Medical Staffing. Upon separation of my employment for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. I have read and understand all privacy policies and procedures that have been provided to me by Pulse Medical Staffing. I agree to all conditions of my employment set forth in this agreement. This is not a contract of employment and does not alter the nature of the at-will employment relationship between Pulse Medical Staffing and me. Signature: ________________________________________ Date: ______________________ Printed Name: _____________________________________ Reviewed by: ______________________________________