Pre-Employment Check List - Pulse Medical Staffing · 620 N. Trade Winds Parkway Suite A Columbia,...
Transcript of Pre-Employment Check List - Pulse Medical Staffing · 620 N. Trade Winds Parkway Suite A Columbia,...
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
GENERAL ASSESSMENT
Admission Procedure Normal vs. Abnormal Vitals
Gathering Prenatal History Pelvic Exam
Initial Physical Assessment S&S of Bleeding
Knowledge of Obstetric Terminology S&S of Ruptured Membranes Fern Testing
Lab Value Interpretation Lab Value Interpretation
INTRAPARTUM CARE
Assessment of: Fetal Malpresentation
(1) Cervical Dilation Fetal Positioning
(2) Effacement Intrapartum Deaths
Fetal Malpositioning Normal Stages of Labor
DELIVERY
Assist with Forceps Delivery Circulate
(1) Type of Forceps: Scrub
Assist with Normal Vaginal Delivery Unassisted Delivery
C-sections: Vacuum Extraction Delivery
POSTPARTUM CARE
Assessment of: (9) Vaginal Changes
(1) Bladder Distension (10) Vitals (normal ranges)
(2) Bowel Function Breast Care
(3) Caesarian Incision Nutritional Considerations for Breast Feeding Mothers
(4) Episiotomy Proper Breast Feeding Techniques and Various Positions
(5) Fundus Consistency Care of Recovering Patient
(6) Homan Sign (1) Epidural Anesthesia
(7) Lochia (2) General Anesthesia
(8) Psychological Status Grieving Mothers (loss of child during birth)
Pain Management
Care of patients with:
D.I.C. Hemolytic Anemias
Gestational Induced Diabetes Malpresentations
Gestational Induced Hypertension Preterm Labor
HIV Disease (1) Assessment of Psychological
Diabetes (2) Considerations of
HELLP Syndrome Rh Incompatibility
Infectious Disease Sickle Cell
Meconium Staining Newborns
Multiple Gestations (1) A.R.D.S.
Placenta Previa or Abruptio Placenta (2) Congenital Anomalies
Preruptured Membranes (3) Cord Prolapse
Preeclampsia/Eclampsia (4) Malformations
(5) Still Births
SKILLS CHECKLIST LABOR/DELIVERY – MOTHER/BABY
2 620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
LABOR/DELIVERY – MOTHER/BABY SKILLS CHECKLIST (continued)
UNIT / SKILLS Exp UNIT / SKILLS Exp
COMPETENCE IN THE FOLLOWING:
Ability to Perform 1 Person Rescue Infant Warmer Usage
(1) CPR - Infant/Child Intubations
(2) CPR - Adult (1) Assisting in Intubations
Ambu Bag Technique (2) Knowledge of ETT Sizes
(1) Adult Universal Isolation Procedures/Precautions
(2) Newborn Isolette Usage
Apnea Monitor Usage Nebulizer Usage
Assist with Amniocentesis NST/CST
Basic EKG Interpretation Oxygen Administration
Use of Blood Pressure Monitor (1) Via Nasal Cannula
Use of Cardiac Monitor (2) Face Mask
Use of Doppler Phototherapy Treatment
Use of Fetal Monitor Sterile Dressing Changes
(1) Normal Ranges Suctioning
(2) Internal Monitor Lead Connection/Calibration (1) Bulb Syringe
(3) Proper Placements (2) Oral
Catheterization (urinary) of: (3) Endotracheal
(1) Female Teaching Infant/Child Safety
(2) Newborn Weighing
Determining Proper Catheter Size Infants
Hyper-Amniotic Fluid Drainage Diapers
Hypothermic Blanket Usage
IV THERAPY
Insertion of Peripheral Line (2) Care of Insertion Site
(1) Newborn Dressing Changes
(2) Newborn Scalp Record Keeping
(3) Adult Hang IV Piggybacks
Administration of IV Meds Use of Bretols for Newborns
Blood/Blood Products Administration (1) Other
Calculate Rates Infusion Pump
(1) Adults (1) IVAC
(2) Newborns (2) IMED
Care of Peripheral Lines S&S of Infection
(1) Infusion Procedures S&S of Infiltration
NEWBORN CARE SKILLS
Apgar Scoring Cord Care
Assessment of Normal Newborn Feeding Techniques for Newborn
(1) Head Circumference (1) Bulb Syringe
(2) Height/Weight (2) Preemie nipple
(3) Vital Signs (3) Med Dropper
Bathing Newborns (4) NG Tube Insertion
Circumcision Care I.D. of Newborn
(1) Assist with Circumcision (1) Footprints
(2) Tri-Band System Policy
3 620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
LABOR/DELIVERY – MOTHER/BABY SKILLS CHECKLIST (continued)
UNIT / SKILLS Exp UNIT / SKILLS Exp
MEDICATION ADMINISTRATION
Epidurals Pain Management & Comfort Measures
(1) Assist with Lumbar Puncture (1) In Relation to Fetal Positioning
Injections Paracervical Blocks
(1) Preparation of Meds/Syringe Use of:
(2) Record Keeping (1) IV Valium
(3) Site Selection (2) IV Narcan
(4) SQ (3) Anti-tocolytics
(5) IM (4) Insulin Drops
Indomethacin (5) Prostaglandins
Insulin Ritodrine
Magnesium Sulfate Terbutaline
Procardia
SPECIMEN COLLECTION
Arterial Blood Gas Draw Interpretation Venipuncture
Blood Culture (1) Adult
Capillary Draw (2) Newborn
Heelstick of Newborn Stool
ADDITIONAL NURSING RESPONSIBILITIES
Discharge - Planning/Teaching SOAP Charting
Knowledge of Unit Doses Charge Nurse Responsibilities
Legal Aspects of Documentation Primary Nurse Responsibilities
Problem Oriented Medical Records Team Leading
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:
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: ______________________________________