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Skills and Procedures Form - Family Medicine | Internal Medicine | Hospitalist
Medicine
Adult Inpatient
Adult Outpatient
ICU/CCU
Hospitalist
Pediatric
Newborn care (>2000 g)
General inpatient
General outpatient
Newborn resuscitation
Occupational Medicine
Disability exams
Diagnosis and management of common industrial-related medical problems
DOT Physical
Women’s Health
Breast exams
Well women’s exams
Surgery
Surgical assisting
Skin/tissue biopsy
Suturing of minor lacerations
I & D (Incision and Drainage)
Psychiatric
Uncomplicated adult
Uncomplicated child/adolescent
Uncomplicated forensic
Uncomplicated geriatric
Emergency Medicine
Would you be interested in working emergency medicine locum tenens assignments?
Yes
No
If yes, please complete a separate Emergency Medicine Skills and Procedures Form.)
Procedures
Please list the approximate number performed within the past 24 months
Arterial line insertion
Swan Ganz placement and monitoring
Central line insertion
Intubation
Chest tube insertion
Ventilator management
Temporary pacemaker insertion and management
Endoscopy
EKG
Paracentesis
Thoracentesis
Lumbar puncture
Other
Other Information
I am comfortable seeing
patients in a
hour shift.
I am comfortable seeing patients that range in age from
to
Are you comfortable with EMR systems?
Yes
No
Are you comfortable working in a solo environment?
Yes
No
Are you comfortable supervising mid-levels?
Yes
No
Are you comfortable responding to codes?
Yes
No
Areas of Interest
Inpatient medicine
Outpatient medicine
Occupational medicine
Acute ambulatory care
Emergency medicine
Rural medicine
Please list any limitations or comments on information provided above:
I affirm that all information provided on this page is true and accurate.
*
Print Name
Date
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