Pre-Employment Check List - Pulse Medical Staffing · Pre-Employment Check List ... Assist in intubation/extubation Tracheostomy oropharyngeal airway trach tray set up

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


CRITICAL CARE SKILLS CHECKLIST (continued)


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


CRITICAL CARE SKILLS CHECKLIST (continued)


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:


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: ______________________________________

Documents

Pre-Employment Check List - Pulse Medical Staffing · Pre-Employment Check List ... Assist in intubation/extubation Tracheostomy *oropharyngeal airway *trach tray set up

Pre-Employment Check List - Pulse Medical Staffing · Pre-Employment Check List ... Assist in intubation/extubation Tracheostomy oropharyngeal airway trach tray set up