pre-employment check list - pulse medical staffing · skills checklist ... assist in...

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.

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 SYSTEM

Assess sensory-motor function extremities Maintain cervical/spinal traction

Assess cranial nerves Use Glascow Coma scale

Assist with lumbar puncture Visual acuity measurement

Care of patients with:

Acute head injury Seizure disorder

Fresh CVA Fresh spinal cord injury

Impending D.T.'s Multi-system trauma

CV/CIRCULATORY

Arrest procedure initiation Defibrillation

*prep & administer meds *arterial line insertion

*family involvement during arrests *exterior pacemaker insertion

Assess heart sounds *Swan Ganz insertion Blood pressure monitoring Set up, run, interpret 12 lead EKG Cardioversion Use of cardiac monitor

Pulse oximetry Use of Doppler

Care of patients with: Fresh MI

Acute aneurysm Pulmonary edema Angina Shock Cardiac contusion *cardiogenic

CHF *hypovolemic

Deep vein thrombosis *septic

RESPIRATORY

Ambu bag techniques Obtain arterial blood gas

Administer oxygen *result interpretation Use of apnea monitor Suctioning Assess lung sounds *use of emergency equipment Assist in intubation/extubation Thoracentesis Chest tube insertion (assist in) Ventilator management Nebulizer set up and use Tracheostomy 1)

*trach tray set up 2)

*assist with emergency trach 3)

Care of patients with: Hemothorax

Acute respiratory distress Pneumonia

Collapsed lung Pulmonary embolism

SKILLS CHECKLIST EMERGENCY ROOM


EMERGENCY ROOM SKILLS CHECKLIST (continued)


GI/GU/REPRODUCTIVE ENDOCRINE Peritoneal lavage

Catheter insertion Poison control

*female Product of conception specimen

*male Rape crisis intervention

D&C procedure *GYN exam

NG tube insertion/lavage *legal ramification of rape exam

Care of patients with: GI bleed

Acute cholecystitis Hyper/hypoglycemia

Acute Renal Failure Multiple abdominal wounds

Appendicitis Pancreatitis

Bowel obstruction Spontaneous abortion

INTEGUMENTARY/ORTHOPEDIC Sizing crutches, teaching use

Cast (fiberglass/plaster) Splints

*application and education of *application of

Cervical, knee and shoulder immobilizers Suture/laceration repair

Care of patients with:

Amputated part Gun shots

Burns Stab wounds

IV THERAPY

Administration/mixing of Iv meds Insertion of central line

Administration of IV fluids *CVP tray set up

Autotransfusion Insertion of peripheral line

Blood/blood product administration Intraosseous infusion

*precautions Pump operations

Calculate doses *IVAC

Calculate rates *IMED

Hang IV piggybacks *Other:

MEDICATION ADMINISTRATION

Injections PO administration

*preparation of meds/syringe SL administration

*site selection (i.e. SQ vs IM)

Use of the following:

Amiodarone Isuprel Atropine Lidocaine Bicarbonate Mannitol Bretylium Morphine Cardizem Nipride Dextrose Nitroglycerin Digitalis Phenobarbital Dopamine Pavulon Epinephrine Pitressin Heparin Thromobolytic meds Insulin Verpamil

PSYCHIATRIC CONSIDERATIONS Psychiatric patient assessment Assessing for domestic violence *care of acute psychotic *child abuse/neglect *care of violent patient *spouse/partner battering *administration of psychiatric medication Monitor chronic alcoholic Use of restraints


EMERGENCY ROOM SKILLS CHECKLIST (continued)


ADDITIONAL NURSING RESPONSIBILITIES Ear irrigation

Specimen collection Eye irrigation

*capillary blood draw Universal isolation procedures/precautions

*sputum Lab value interpretation

*stool Organ procurement

*venipuncture/adult Postmortem procedure

*venipuncture/child Pre-op teaching

*wound culture Post-op teaching

Initial assessment/documentation Problem oriented medical charts

Charge nurse responsibilities Triage/RN role

Discharge planning/teaching Use of EMS system/radio

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.

Signature:

Date:

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:


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:


---------------------------------------------------------------------------------------------------------------- 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:


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._____________________________


--------------------------------------------------------------------------------------------------------------------------------------------------------------

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: ______________________________________________


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: _______________________________


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: ______________________________________

pre-employment check list - pulse medical staffing · skills checklist ... assist in...

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