Forms - Royalty Medical Solutions Inc

Applicant Forms

Please fill out applicable forms completely in order to complete your employment assessments and application.

RN L&D Form

Name
First Last
0 = Not Applicable
1 = No Experience
2 = Some Experience
3 = Intermittent Experience
4 = Experience
5 = Very Experience

*Required Fields

AGE OF PATIENT CARED FOR*

	0	1	2	3	4	5
Newborn/Neonate (Birth to 30 days)*
Infant (1 month to 1 year)*
Toddler (1 year to 3 years)*
Preschooler (3 years to 5 years)*
School Age Child (5 years to 12 years)*
Adolescents (12 years to 18 years)*
Young Adults (18 years to 39 years)*
Middle Adults (39 years to 64 years)*
Older Adults (64 years to 79 years)*
Elderly Adults (over 79+ years)*

GENERAL SKILLS*

	0	1	2	3	4	5
Patient and Family Teaching*
Coaching Needs*
Universal Precautions*
Isolation Precautions*
Care of the Patient in restraints*
Cardiac Monitoring*
Pulse Oximetry*
Ventilator Management (Adult)*
Ventilator Management (Newborn)*
Prep and Administration of Emergency Meds*
Infant/ Neonatal Cardiac/ Respiratory Arrest*
Adult Cardiac/ Respiratory Arrest*
End of Life Care*
Fetal Monitoring- Basic*
Fetal Monitoring- Advanced*
IV Therapy*
Administration of Blood/ Blood Products.*
Knowledge of Normal Lab Values*
Newborn*
Labor Patient*
Pain Management*
Automated Med Dispensing System*

List Types:
Automated Med Dispensing System

List Types:
Electronic Documentation*

List Types:
CARE OF PATIENTS WITH PRE-EXISTING CONDITIONS/ HIGH

Cardiac Disease*

Neurological Disease*

Seizure Disorder*

Chronic Diabetes Mellitus*

Pregnancy Induced Diabetes Mellitus*

Asthma*

Chronic Hypertension*

Pregnancy- Induced Hypertension*

Infectious Disease*

HBV*

HIV*

Sickle Cell Disease*

RH Incompatibilities*

Hemolytic Anemia*

Collagen Vascular Disease*

Hemorrhage*

Drug Addiction/ Withdrawal*

Pyelonephritis*

Abruptio Placenta*

Placenta Previa*

Placenta Acreta*

Preeclampsia*

Eclampsia*

Premature Labor*

Malpresentations*

Breech*

Transverse Lie/ Shoulder*

Face Presentation*

Brow Presentation*

Multiple Gestation*

PROM*

Chorioamnionitis*

Poly/ Oligohydramnios*

Prior Tubal Ligation*

VBAC Management/ Trial of Labor*

Uterine Rupture*

Incompetent Cervex (Shirodkar Suture/ Cerclage)*

Spontaneous Abortions- Complete/ Incomplete*

Intrauterine Growth Retardation (IUGR)*

Postdate Pregnancy*

HELLP Syndrome*

DIC*

Fetal Demise*

CARE OF PATIENTS WITH PRE-EXISTING CONDITIONS/ HIGH*

	0	1	2	3	4	5
Cardiac Disease*

Neurological Disease*

Seizure Disorder*

Chronic Diabetes Mellitus*

Pregnancy Induced Diabetes Mellitus*

Asthma*

Chronic Hypertension*

Pregnancy- Induced Hypertension*

Infectious Disease*

HBV*

HIV*

Sickle Cell Disease*

RH Incompatibilities*

Hemolytic Anemia*

Collagen Vascular Disease*

Hemorrhage*

Drug Addiction/ Withdrawal*

Pyelonephritis*

Abruptio Placenta*

Placenta Previa*

Placenta Acreta*

Preeclampsia*

Eclampsia*

Premature Labor*

Malpresentations*

Breech*

Transverse Lie/ Shoulder*

Face Presentation*

Brow Presentation*

Multiple Gestation*

PROM*

Chorioamnionitis*

Poly/ Oligohydramnios*

Prior Tubal Ligation*

VBAC Management/ Trial of Labor*

Uterine Rupture*

Incompetent Cervex (Shirodkar Suture/ Cerclage)*

Spontaneous Abortions- Complete/ Incomplete*

Intrauterine Growth Retardation (IUGR)*

Postdate Pregnancy*

HELLP Syndrome*

DIC*

Fetal Demise*

ANTEPARTUM*

	0	1	2	3	4	5
Triage of Obstetrical Patients*

Assessment of Birth Plan*

Perform Admission Risk Assessment*

Non- Stress Test (NST)*

Induction of Labor*

Oxytocin Challenge Tests (OCT)*

Biophysical Profile*

Assist with Sonogram*

Perform Sonogram*

Assist with Amniocentesis*

Normal Perinatal Vital Signs*

Deep Tendon Reflex Checks (DTR’s)*

Edema Assessment*

Clonus*

Assess for Comfort*

Breathing/ Relaxation Techniques*

Coaching*

Positioning*

MEDICATIONS*

	0	1	2	3	4	5
Ritodrine*

Magnesium Sulfate*

Terbutaline*

Indomethacin*

Procardia*

Pitocin*

Oxytocin*

Cervidil*

Cytotec*

Prostin Suppositories*

Assist with Prostin Gel*

Antibiotics*

Antihypertensives*

Heparin*

Stadol*

Nubain*

Morphine*

Demerol*

Fentanyl*

Insulin Drips*

Insulin Pumps*

Insulin SC*

AZT/ Other Antiviral Medications*

Rhogam*

IV THERAPY/ PROCEDURES*

	0	1	2	3	4	5
Starting PIV’s*

PICC Lines- Care and Maintenance*

Central Venous Lines- Care and Maintenance*

Invasive Hemodynamic Monitoring*

Blood Draw from PICC/ CVL*

Administration of Blood/ Blood Products*

IV Infusion Pumps*

Blood/ Fluid Warmers*

LABOR ASSESSMENT/ PROCEDURES: MATERNAL:*

	0	1	2	3	4	5
Normal Vital Signs- Baseline*

Identify Common Cardiac Arrhythmias*

Assist with Sterile Speculum Exam*

Perform Sterile Speculum Exam*

Vaginal Exam- Manual*

Status of Membranes*

Assist with Rupture of Membranes*

Fern Test*

Nitrazine*

Presence of Clonus*

DTR’s*

Edema*

Progression Of Labor*

Dilation*

Effacement*

Fetal Position*

Fetal Presentation*

Station*

Contraction Characteristics*

Determination of Fetal Head Position*

Documentation of Labor Status and Interventions*

Labor Suppressants*

Collection of Blood Specimens*

Collect Urine Specimens*

Toxicology Studies*

Collect Vaginal Cultures*

Fluid*

Herpes*

Chlamydia*

Group B Strep*

Perform Leopold’s Maneuvers*

Amnioinfusion (assist or perform) for:
Variable Decelerations*

Meconium*

Prolapsed Cord*

Vasa Previa*

Catheter Insertion Straight Cath*

Foley*

LABOR ASSESSMENT/ PROCEDURES: FETAL:*

	0	1	2	3	4	5
Fetal Heart Rate- Doppler*

Fetal Heart Rate- Auscultate*

Document Fetal Position*

Fetal Heart Rate Patterns: Identify & Treat Baseline
Variability*

Variable Decelerations* ntrauterine Pressure Catheter (IUPC) Placement*

Early Decelerations*

Late Decelerations*

Prolonged Decelerations*

External Fetal Monitor Application*

Internal Fetal Monitor Application (Assist)*

Internal Fetal Monitor Application (Perform)*

Spiral Electrode*

Intrauterine Pressure Catheter (IUPC) Placement*

Calibration*

Fluid Filled*

Transducer Tipped*

DELIVERY/ C-SECTION*

	0	1	2	3	4	5
Assist with Vaginal Delivery*

Forceps Extraction*

Vacuum Extraction*

Assist with High Risk Delivery*

Shoulder Dystocia* Hemorrhage/ Shock*

Emergency Delivery*

Abdominal Shave/ Scrub Prep*

Perineal Prep*

Circulate for C-Section*

Scrub for C-Section*

Patient with General Anesthesia*

Patient with Epidural Anesthesia*

Circulate with Tubal Ligation*

Scrub for Tubal Ligation*

Assist with Placenta Delivery*

Fundus Massage*

Assist with Cervical Laceration Repair*

Assist with Uterine Laceration Repair*

Assist with Episiotomy Repair*

IMMEDIATE CARE OF NEWBORN IN DELIVERY ROOM*

	0	1	2	3	4	5
Newborn Assessment Ballard*

Dubowitz*

Finnegan/ Abstinence Scoring*

Apgar Scores*

Initial Vital Signs*

Bulb Suctioning*

Delee Suctioning*

Wall Suctioning*

Meconium Aspiration*

Collect Cord Samples*

Assist with UAC/ UVC Insertion*

Insertion of IV, Including Scalp IV*

Radiant Warmer/ Thermoregulation*

Interventions for LGA, SGA, IUGR*

Interventions for Infant of Diabetic Mother*

Oxygen Administration*

Bag/ Mask Ventilation of the Newborn*

Assist with Intubation*

Transport Isolette*

Heelstick Glucose*

Eye Prophylaxis*

Vitamin K*

ID/ Security Banding*

Promote Bonding Behaviors*

Lead Placement for Cardiac Monitor*

Apnea Monitoring*

Oxyhood*

POSTPARTUM CARE*

	0	1	2	3	4	5
Fundal Height*

Fundal Massage* Lochia*

Episiotomy Care*

Perineum Care*

Maternal Vital Signs*

Recovering Post-Op C-Section Patients*

Recovering Post-Op Tubal Ligation Patient*

Fluid Balance*

Assessment for DVT*

Couplet Care*

Breast Care*

Breastfeeding*

Assists in plans and goals for lactation services

NEWBORN CARE*
0 1 2 3 4 5
Cord Care*
Circumcision Care*
Bath Demonstration*
Assist with Lumbar Puncture*
Administration of IV Antibiotics*
Newborn Vital Signs*
Assist with Breastfeeding Latch On*
Positioning*

CARE OF THE INFANT WITH*

	0	1	2	3	4	5
Cardiac Anomalies*

Drug Addiction/ Withdrawal*

Cystic Fibrosis*

Meconium Aspiration*

Pneumonia*

Pulmonary Edema* RDS*

NEC*

Neuromuscular Disease*

Spina Bifida*

Seizure Activity*

Tracheoesophageal Fistula*

Sepsis*

Sickle Cell Disease*

Low Birth Weight Infants*

PAIN MANAGEMENT/ANESTHESIA*

	0	1	2	3	4	5
Assess Pain Level*

Assess Acceptable Level of Pain*

Intranasal Pain Medications*

Oral Pain Medications*

IV Pain Medications*

PCA*

IV Conscious Sedation*

Epidural Pain Management*

Intervention for Anesthesia Toxicity*

Assist with Epidural Insertion Positioning of Patient*

Signs of Dural Puncture*

Fluid Challenge*

Hypotension*

Intrathecal Narcotics*

List any Additional Training:
List any Additional Skills:
List Any Additional Equipment:
Experience with ventilators?***
- Yes
- No
Experience with cardiac monitors?***
- Yes
- No
NRP current?**
- Yes
- No
STABLE current?**
- Yes
- No
Fetal monitoring course – basic?**
- Yes
- No
Fetal monitoring course – intermediate?**
- Yes
- No
Fetal monitoring course – advanced?**
- Yes
- No
My experience is mostly in…(list number of years in each setting)
Labor and Delivery*
LDR:**
LDRP:**
Community Hospital (Also list number of births per month):**
Number of deliveries per month (average in last year):**
Have you ever experience an unattended delivery:**
Application Agreement
I certify that the information provided above accurately reflects education received and my experience in each of the clinical areas identified within the last 2 years. The information I have given is true and accurate to the best of my knowledge, and I hereby authorize Royalty Medical Solutions Inc to submit this skills evaluation to their clients. To be updated annually.
Signature
Date
Date Format: MM slash DD slash YYYY
Name
First Last
Specialty Lactation Consultant
First Last
Applicant Email
Applicant Phone

Medical Assistant Skills Checklist

Name
First Last
0 = Not Applicable
1 = No Experience
2 = Some Experience
3 = Intermittent Experience
4 = Experience
5 = Very Experience

*Required Fields

AGE*

	0	1	2	3	4	5
Newborn (Birth to 30 days)*
Infant (1 month to 1 year)*
Toddler (1 year to 3 years)*
Preschooler (3 years to 5 years)*
School Age Child (5 years to 12 years)*
Adolescents (12 years to 18 years)*
Young Adults (18 years to 39 years)*
Middle Adults (39 years to 64 years)*
Older Adults (64 years to 79 years)*
Elderly Adults (over 79+ years)*

Specialty Experience*
0 1 2 3 4 5
Gynecology
Family Practice
Obstetrics
Oncology
Orthopedics
Pediatrics
Post Portum
Renal/dialysis
Outpatient clinic

Back Office Skills*

	0	1	2	3	4	5
Transcribing
Taking Patient’s History
Ability to perform spirometry
Ability to perform EKG
Ability to use a centrifuge
Ability to use a Stethoscope
Nebulizer
Vitals: Pulse oximeter, Blood Pressure, Tempature
Oxygen

Labs:*
0 1 2 3 4 5
Phlebotomy: venipuncture
Urinalysis
Collection of Specimen
Stool Collection
Vision Testing
Pregnancy Test
Vaginal Swabs
Wound Swabs
Throat Swabs
Hearing Screening
Other: List
List any Additional Labs:
I certify that the information provided above accurately reflects education received and my experience in each of the clinical areas identified within the last 2 years. I hereby release this self assessment of skills to clients of Royalty Medical Solutions.
Name
First Last
Signature
Date
Date Format: MM slash DD slash YYYY

	0	1	2	3	4	5
Gynecology
Family Practice
Obstetrics
Oncology
Orthopedics
Pediatrics
Post Portum
Renal/dialysis
Outpatient clinic

	0	1	2	3	4	5
Phlebotomy: venipuncture
Urinalysis
Collection of Specimen
Stool Collection
Vision Testing
Pregnancy Test
Vaginal Swabs
Wound Swabs
Throat Swabs
Hearing Screening
Other: List

Applicant Forms

My experience is mostly in…(list number of years in each setting)

Application Agreement