Precise HealthCare Solutions · Precise Healthcare Solutions Precise HealthCare Solutions 12/2005 Additional Information Have you been convicted of a felony that would prohibit your

Precise Healthcare Solutions

Precise HealthCare Solutions 12/2005

Precise HealthCare Solutions Application Please print clearly and use black ink only

Personal Information Date of Application __________________________ Date Available for Work_______________________ Name First____________________ M._______________________ Last__________________________ Mailing Address ______________________________________________________________ __________________________________________________________________________ Current Address ______________________________________________________________ __________________________________________________________________________ # Of Years at this Address___________ Email Address _______________________________________ Previous Address _____________________________________________________________ __________________________________________________________________________ Social Security #_____________________________________ Current Phone # ________________________ Permanent Phone_______________________________ Other method of contact(pager, cellular, etc) ________________________________________________ Emergency Contact _________________________Relationship to Contractor _____________________ PhoneNumber __________________________________________________ Education Name and location of school (s) Graduation Date Type of Degree ____________________________________ __________________ _______________________ ____________________________________ __________________ _______________________ ____________________________________ __________________ _______________________ ____________________________________ __________________ _______________________



Licensure State Type of License Expiration Date License/Cert. Number ________ _____________________ _________________ _______________________________ ________ _____________________ _________________ _______________________________ ________ _____________________ _________________ _______________________________ ________ _____________________ _________________ _______________________________ ________ _____________________ _________________ _______________________________ ________ _____________________ _________________ _______________________________ ________ _____________________ _________________ _______________________________ Which of these licenses is your original state of licensure? _____________________________________ Has your license or certification ever been revoked or under suspension? □ yes □ no If yes, please explain ___________________________________________________________________ ____________________________________________________________________________________ Resuscitation Credentials Place the date of expiration next to your credential (s) ACLS ________________________ BLS ____________________ ENPC ______________________ NRP _________________________ PALS ___________________ TNCC _______________________ Continuing Education Date Name of Course CEU's Earned _________ ____________________________________________________ ________________ _________ ____________________________________________________ ________________ _________ ____________________________________________________ ________________ _________ ____________________________________________________ ________________ Professional Certifications Type Expiration Date ________________________________________________________________ __________________ ________________________________________________________________ __________________ ________________________________________________________________ __________________ ________________________________________________________________ __________________



Additional Information Have you been convicted of a felony that would prohibit your assignment at a health care facility: □ yes □ no Have you ever been convicted of any law violation? Include any plea of "guilty" or "no contest". (Exclude minor traffic violations) □ yes □ no If yes, give details _____________________________________________________________________ ____________________________________________________________________________________

(A conviction will not necessarily disqualify an applicant for employment)

Are you currently employed? □ yes □ no If yes, may we contact your employer? □ yes □ no Employer Name & Contact ______________________________________________________________ ____________________________________________________________________________________ I would be interested in a travel assignment with Precise HealthCare Solutions. □ yes □ no I would be interested in positions within the state of Georgia. □ yes □ no My availability is as follows: □ Mon □ Tues □ Wed □ Thur □ Fri □ Sat □ Sun □ 7- 3 □ 3-11 □ 11-7 □ 7a-7p □ 7p-7a □ Any shifts that are available Employment Experience Provide information for any job held within the last 3 years. Do not substitute your resume. Employment dates From ___/___/___ to ___/___/___ Agency(if used) ____________________________ Hospital/Facility _______________________ Address ________________________________________ City & State __________________________ Supervisor ______________________________________ Phone ______________________________ Fax ____________________________________________ □ Full time □ Part Time □ Agency Contract For what period of time?_____________________________ Employment dates From ___/___/___ to ___/___/___ Agency(if used) ____________________________ Hospital/Facility _______________________ Address ________________________________________ City & State __________________________ Supervisor ______________________________________ Phone ______________________________ Fax ____________________________________________ □ Full time □ Part Time □ Agency Contract For what period of time?_____________________________



Employment dates From ___/___/___ to ___/___/___ Agency(if used) ____________________________ Hospital/Facility _______________________ Address ________________________________________ City & State __________________________ Supervisor ______________________________________ Phone ______________________________ Fax ____________________________________________ □ Full time □ Part Time □ Agency Contract For what period of time?_____________________________ Employment dates From ___/___/___ to ___/___/___ Agency(if used) ____________________________ Hospital/Facility _______________________ Address ________________________________________ City & State __________________________ Supervisor ______________________________________ Phone ______________________________ Fax ____________________________________________ □ Full time □ Part Time □ Agency Contract For what period of time? _____________________________ Personal References (please list persons not related to you who have known you at least one year): Name City, St Phone # ____________________________ ________________________________ ___________________ ____________________________ ________________________________ ___________________ ____________________________ ________________________________ ___________________ Referred by(select one of the following): □ Newspaper (city & name of paper) ______________________________________________________ □ Direct Mail □ Internet Web Ad □ Search Engine Yahoo, MSN, Google, etc) _________________ □ Careerbuilder or Top Jobs (city &/or name of paper) ________________________________________ □ Referred by a friend (important! Name of friend)____________________________________________ □ Job Fair (city) _____________________________ □ Phone book ____________________________ Have you ever worked for Precise HealthCare Solutions? □ yes □ no If yes, which Precise HealthCare Solutions office was your home base and when was your last assingment? _________________________________________________________________________ Date ______________________________ Signature __________________________



PROFESSIONAL REFERENCE RELEASE: I authorize ________________________________from ________________________ Name of Healthcare Manager Name of Facility to release information about me for the purpose of supplying a reference check. ________________________________________ Date ________________________ Signature of Healthcare Applicant Print Name___________________________ Social Security #___________________ Certification or Licensure of Healthcare Applicant: ___CNA ___LPN ___RN ___RAD TECH ___RT (Respiratory) ___CRTT ___OT ___PT ___Speech ___COTA___PTA ___OTHER DATES OF EMPLOYMENT: FROM:________________TO:____________________ REASON ENGAGEMENT ENDED:_________________________________________

EVALUATION EXCELLENT GOOD AVERAGE POOR Dependability Quality at Work Job Knowledge Accepts Supervision Personal Appearance Attuide Would you rehire this individual? YES ______ NO _______ If no, please explain:______________________________________________________ __________________________________________________________________________________________________________________________________________ _______________________________________ Employer’s Signature Date Thank you for your assistance. Please fax the document to HR at: 1-877-294-7650



PROFESSIONAL REFERENCE RELEASE: I authorize ________________________________from ________________________ Name of Healthcare Manager Name of Facility to release information about me for the purpose of supplying a reference check. ________________________________________ Date ________________________ Signature of Healthcare Applicant Print Name___________________________ Social Security #___________________ Certification or Licensure of Healthcare Applicant: ___CNA ___LPN ___RN ___RAD TECH ___RT (Respiratory) ___CRTT ___OT ___PT ___Speech ___COTA___PTA ___OTHER DATES OF EMPLOYMENT: FROM:________________TO:____________________ REASON ENGAGEMENT ENDED:_________________________________________

EVALUATION EXCELLENT GOOD AVERAGE POOR Dependability Quality at Work Job Knowledge Accepts Supervision Personal Appearance Attuide Would you rehire this individual? YES ______ NO _______ If no, please explain:______________________________________________________ __________________________________________________________________________________________________________________________________________ _______________________________________ Employer’s Signature Date Thank you for your assistance. Please fax the document to HR at: 1-877-294-7650



Precise HealthCare Solutions Independent-Contractor Agreement This Agreement dated this _______________day of _________________, 20___, is executed by and between Precise HealthCare Solutions of _________________________, located at ______________________________ and ____________________________________________

WHEREAS, Contractor is independently engaged in the business of performing caregiver services for clients; WHEREAS, Company is engaged in the business of screening self-employed caregivers, assisting in identifying

client-engagement opportunities, and in handling certain administrative aspects of billing and collections on their behalf; and WHEREAS, Contractor seeks to engage Company to verify Contractor’s background and professional

qualifications, to assist Contractor in identifying potential client opportunities and to assist Contractor in billing and collecting fees that Contractor earns by providing services for clients referred by Company.

Now, therefore, in consideration of the mutual promises and covenants of the parties as herein contained, those parties hereto have agreed and contracted as follows:

1. Contractor hereby engages Company to verify Contractor’s background and professional credentials and to refer engagement opportunities with clients that seek the type of services that Contractor is in the business of providing.

2. Company shall bill and collect on Contractor’s behalf the fees that Contractor earns by performing services for a client referred by Company (“Referred Client”). Contractor’s fees for performing services hereunder shall be negotiated separately. For purposes of this Agreement, all services a Contractor perform for a Referred Client will be treated as derived from Company’s referral, unless (i) the services are performed subsequent to the 90th day following Company’s receipt of a written notice from Contractor advising that the client referral has ended, and (ii) Contractor does not provide any services for the client during that 90-day period. If contractor performs any services for a Referred Client that are derived from Company’s referral under an arrangement that is outside the terms of this Agreement, Contractor shall be deemed in breach of this Agreement. This shall include, but not be limited to, “flex pool”- “P.R.N. pools” or any other type of service performed for a Referral Client. In light of the difficulty in establishing the amount of damages Company would suffer upon such a breach, the parties agree that Company shall be entitled to recover from and against Contractor, upon such a breach, liquidated damages in the amount of ten thousand dollars, ($10,000.00) per each occurrence.

3. The original term of this Agreement shall be for one year, commencing on the _________ day of _______________, 20______. This Agreement shall be renewed automatically for an additional 12-month periods, unless either party advises the other party in writing of an intent not to renew this Agreement no later than 30 days prior to the termination of the then-current term hereof.

4. Contractor has the right to refuse any engagement offered hereunder for any reason and Contractor is not prohibited from marketing Contractor’s services through other means, including through other similar agencies or to potential clients directly. Company does not contemplate being able to offer Contractor a sufficient number of client engagements to allow Contractor to devote full-time efforts to the performance of services hereunder.

5. Contractor shall have exclusive control over the means, methods, and details of performing any client engagement undertaken hereunder, and Company will not provide Contractor with any training, tools, equipment, or other assistance in completing an engagement.



6. Contractor is solely responsible for all federal, state, and local income and employment taxes, and for complying with all federal, state, and local laws, including state workers’ compensation laws, that relate to services performed for clients.

7. This Agreement will be interpreted and construed under the laws of the State of Florida, excluding any choice of law rules.

8. Any dispute between Contractor and Company arising out of or in any way relating to this Agreement, including its validity, enforceability, interpretation, performance or breach, shall be subject to binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association, or any successor thereto then prevailing. Such arbitration shall be final and binding upon the parties and shall be the sole and exclusive remedy of the parties with respect to any such dispute. The cost of such arbitration shall be borne equally by the parties. This paragraph shall survive the termination of this Agreement.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the day and year first above written. Precise HealthCare Solutions Contractor _________________________________________ ________________________________ Signature d/b/a if applicable _________________________________________ _________________________________ Title Signature _________________________________________ _________________________________ Date Date



REGISTERED NURSE SKILLS CHECKLIST PERSONAL DATA Key

Number - Level of Proficiency 0 - No experience 1 - Minimal experience needs, review and supervision 2 - Can perform without supervision 3 - Performs well and can set as a resource person

Name__________________________________ Print Signature____________________Date_____________ DIRECTIONS: By accurately filling out this checklist, you will help us match your skills and interests with available assignments at our client hospitals. Please check the appropriate boxes to describe your experience level with each skill.

CARDIOVASCULAR 0 1 2 3 Use of Cardiac Monitors Recognizing Arrythmias Obtaining and Interpreting 12 Lead ECG

Cardio Pulmonary Arrests Cardio Version Defibrillation Intra-Aortic Balloon Pump Care of Immediate Open Heart Pt. Care of 24-48 hr. Post-Op Open Heart Patient Pre/Post-Op Cardiac Transplant Pre-Post-Op Angioplasty Post-Op Vascular Surgery Patient (i.e. Aneurysms) Pre-Post Cardiac Catherization Care of Pt. W/Valvular Diesease Cardiogenic/Hypovolemic Shock Hemodynamic Monitoring set up and care for patient with: Central Venous Catheter Subclavian Lines Swan-Ganz Catheter Aterial Catheter Right Ventricular Pressure Pulmonary Artery Pressure Pulmonary Capillary

0 1 2 3 Heparin Lidocaine Nipride Dopamine Isupre Digitalis Sodium Bicarbonate NEUROLOGY Neuro Assessment/Neuro Vitals ICP Monitoring Seizure Precautions Stryker Frame Crutchfield Tongs Halo Traction Care of Patient with: Spinal Cord Injury Pre-Post Neurological Surgery Degenerative Diseases of: Nervous System Drug Overdoses Acute Head Injury Cerebral Aneurysm Acute/Chronic C.V.A./T.I.A. Rehabilitation of the Neuro Pt. RESPIRATORY Assessment of Breath Sounds Assist w/Set-Up Maint. Of: Chest Tubes Continuous O2 SAT and CO2 Monitoring Equipment



Wedge Pressure Left Atrial Pressure Care of Patient receiving T-PA or Assist w/setting up for Streptokinase

Use and Administration of the following drugs: Atropine Epinephrine Dobutrex Tridil Verapamil. Procainamide Dobutamine Esmolol Pronestyl GASTROINTESTINAL Assessment of Bowel Sounds Identification Abnormalities Stool Tests Insert/Maintain Feeding Tubes Administration Tube Feedings Insert/Maintain Intermittent/ Continuous Suction NG Tubes Care of Acute GI Bleed Abdominal Wounds or Infections Pre-Post-Op GI Surgery Colostomy Care Dehiscence Care of Pt. On Total Parenteral Nutrition

ORTHOPEDICS Traction Braces Casts Collars Slings Splints Skeletal Skin

Pulmonary Emboli

Care of Patient with: 0 1 Tracheostomy Pre-Post Thoracic Surgery COPD ARDS Use of Chest Drainage Systems Assist w/Intubation/Extubation Ambuing Technique Administer O2 (nasal,canula, Cardiac Output mast,endo-tracheal)

Bronchoscopy Ventilators: Use and Complication of PEEP Use and Complication of CPAP Use and Complication of IMV Weaning ABG Analysis-mixed Venous ABG analysis RENAL/GENITOURINARY Ability to Insert/Maintain Urinary Drainage Tubes Care of Patient With: Acute Renal Failure Chronic Renal Failure Post Renal/Genitourinary Surgery Pre-Post-Op Renal Transplant Care of Patient on Peritoneal Dialysis

Care of Patient on Hemodialysis Assessment of Fluid and Electrolyte Problems

ENDOCRINE

Admn. Of IV Insulin Drip Blood Glucose Checks Care of Patient in Diabetic Ketoacidosis

Hormone Therapy



ORTHOPEDICS (cont) 0 1 2 3 Beds,i.e. Clinitron,Roto Rest, Circelectric Crutch Walking/Walkers Total Knee Replacement Total Hip Replacement Arthroscopy/Arthrotomy Care of Patient with: Joint Disorders Bone Disorders Amputation

ONCOLOGY 0 1 2 3 Care of the Aids Patient Colostomy/Ileostomy Isolation/Universal Precautions Pain Management OTHER Burn Patients Use of Hypothermia/ Hyperthermia Blanket Inserting IV’s IV Therapy Set-up for Cut Down Admn & Monitoring of IV Antiocagulants

Admn of Blood and Blood Products Obtaining Venous Blood Knowledge of Serum Lab Values Specimen Collections Care of Drains/Tubes (i.e. Hemovac, etc.) Charge Experience

Have you had a formal critical care course? ___________________________________________________________________________ Is your experience primarily: ___CCU ___ER ___MICU ___SICU ___TELEMETRY/STEPDOWN ___CVICU ___IMCU ___NICU ___RR/PACU Are you ACLS certified? ___Yes ___No Do you have your CCNR? ___Yes ___No Are you IV Certified? ___Yes ___No Signature_______________________________ Print Name ___________________________________ Date ___________________________________



RELEASE OF INFORMATION

DRUG SCREENS. Should the facility request, I consent to a urine, blood or breath sample for the purposes of an alcohol, drug, intoxicant, or substance abuse screening test. I also give permission for the release of the test results for determining my fitness for assignments. BACKGROUND SCREEN. Before I am placed in any Precise HealthCare Solutions client facility, Precise HealthCare Solutions will conduct a background screen (Level I or Level II) for the sole purpose of determining fitness to serve in the capacity of caregiver. I understand I will be charged a fee of $25.00 which will be deducted from the first compensation I receive. I also give permission for release of the results for determining my fitness for assignment. BACKGROUND AND MEDICAL INFORMATION RELEASE. I authorize Precise HealthCare Solutions to release any and all confidential background and medical information contained in my contractor file to any medical facility or entity with whom Precise HealthCare Solutions has a staffing agreement, and to any other governmental or regulatory agency at such agency’s request. For all other purposes, Precise HealthCare Solutions shall keep my background and medical records confidential and shall advise any medical facility or other entity to whom records have been provided to also keep such records confidential. I hereby release and holdPrecise HealthCare Solutions harmless for any result(s) that may arise with regard to the release of this confidential information by Precise HealthCare Solutions. I also authorize all hospitals, institutions or organizations, personal physicians, employers and all governmental agencies and instrumentalities (local, state and federal) to release toPrecise HealthCare Solutions any information which is material to my application to contract with Precise HealthCare Solutions to obtain client referrals. ________________________________________ ___________________ Signature of Contractor Date ________________________________________ Print Name



PHYSICIAN’S STATEMENT

INDEPENDENT CONTRACTOR:__________________________________________________________ (please print)

Note: It is your responsibility to have your physician fill out the appropriate section of this form.

PHYSICIAN TO COMPLETE THE FOLLOWING SECTION: TB SKIN TEST DATE RESULTS DATE_________________ RESULTS_____________________ (print “N/A” if not applicable) CHEST XRAY (if TB test is positive) DATE_________________ RESULTS_____________________ (print “N/A” if not applicable) FREE OF COMMUNICABLE DISEASES _____YES _____NO DATE ________________ (print “N/A” if not applicable) I have examined the individual above and to the best of my knowledge, he/she is in good physical and mental health (without any restrictions), free of any communicable diseases, and is able to function in his/her profession at full capacity. By signing below, I certify that the above information is valid. ______________________________________________________ _______________________ Physician Signature Date ______________________________________________________ _______________________ Print Physician’s Name Date

As the Independent Contractor, you must fill out the following: ___ I understand the OSHA guidelines and DECLINE the Hepatitis B Vaccination. Signature __________________________________________ Date_________________________ ___I understand the OSHA guidelines and need #____or booster, in the series. Please arrange for me to receive this dose of the vaccine. Signature__________________________________________ Date_________________________



Authorization for Electronic Payment

(Quarterly Federal Estimated Tax Payments) I hereby authorize Precise HealthCare Solutions to establish and ma intain an electronic account with the Internal Revenue Service on my behalf. The purpose for this account is the payment of quarterly estimated tax payments. By inserting the information below, I voluntarily elect to have the money deducted from my compensation and held until such time as quarterly payment is due. I further understand that I will be notified of the sum total of my annual tax payments for tax purposes in January of each year. Name (as appears on your tax return, Please PRINT clearly): ____________________________________________________________________________________ Maiden Name (if Applicable):___________________________________________________________ Social Security Number: _______________/_________ /_______________ Address at the end of last Tax year: Street:_______________________________________________________________________________ City: ___________________________________State:__________ Zip___________________________ ________________________________________________ _____________ Signature Date



ACKNOWLEDGMENT REGARDING TAX WITHHOLDING

I understand that as an Independent Contractor with Precise HealthCare Solutions , I am responsible for all Federal Income Tax, Social Security Tax and Medicare payments. Precise HealthCare Solutions will however withhold Federal Income Tax at your request. Please mark the applicable box below and acknowledge by signature. ___Yes, I request Precise HealthCare Solutions to withhold Federal Income Tax. I will be responsible for any Social Security Taxes and Medicare withholdings. • I wish to file: ___Single ___Married or ___Married but withhold at a higher Single rate. • The total number of allowances I claim is: ________ • Please withhold $___________ in addition to my Federal Income Tax. ___No, I will be responsible for my own Federal Income Tax, Social Security Taxes and Medicare withholdings. ***I understand that a Law Enforcement Background Screen will implemented and I will be responsible for any cost incurred in this process. _____________________________________ _____________________ Signature of Contractor Date



Medication Test 1. The chief danger in giving an IM injection in the wrong area of the buttock is: a. poor absorption b. formation of an abscess secondary to fecal contamination c. damage to sciatic nerve or penetration of a large blood vessel d. damage to underlying bony tissue 2. The most appropriate size needle for administering an IM injection to a 200 lb male with a non-viscous solution is:

a. 1”, 20 gauge b. ½”, 25 gauge c. 1 1/2”, 18 gauge d. 1 ½”, 22 or 23 gauge

3. The most appropriate site for IM injection in a small children and infants is: a. the dorsogluteal site b. the ventrogluteal c. the deltoid site d. the vastus lateralis site 4. Betagan eyedrops are ordered for a patient. Which of theses abbreviations indicate the eyedrops are to be instilled into both of the patient’s eyes?

a. o.u. b. o.d. c. o.s. d. o.b.

5. Intradermal injections are most often used to administer: a. substances for skins tests b. oil preparations c. large amounts of fluid that cannot be given IV d. drugs that are irritating to muscle tissue 6. Colestid 1 g is ordered BID, a.c. This means to administer it: a. with meals b. before meals c. after meals d. without regard to meals



Medication Test 7. All of the following are correct statements about subcutaneous injections EXCEPT: a. use a needle 3/8” -5/8” in length of 25-27 gauge b. inject the needle quickly and firmly at 90 degree angle c. pull back on plunger to aspirate for blood return

d. do not massage the site if giving subcutaneous heparin

8. Which of the following are the most important considerations when administering a drug via IV push:

a. use a medium gauge needle or needleless cannula b. check for blood return in IV line c. consider the diluent that is used to reconstitute the medication d. check the recommended rate for administering each bolus medication

9. Which of the following are appropriate patient education instructions to the patient taking a medication sublingually:

a. drink a full glass of water after swallowing it b. rinse your mouth with medication, but do not swallow it c. chew the medication thoroughly before swallowing it d. hold the medication under your tongue until it is dissolved

10. All of the statements below are appropriate patient education for a patient starting on an antihypertensive Except:

a. rise slowly when getting up from a horizontal position b. you may become lightheaded or dizzy if you take very hot baths or showers c. limit your fluid intake to only 6 glasses per day d. don’t stand on one spot for a long period of time

11. Which of the following are patient symptoms reflecting a potential drug allergy requiring immediate treatment:

a. extreme muscular tremors b. edema of face and hands c. difficulty breathing & falling blood pressure d. diaphoretic and shaking

12. If a patient had an anaphylactic reaction to penicillin, which of the following drugs are contraindicated for this patient?

a. Erythromycin b. Aminoglycosides c. Tetracycline d. Cephalosporins



Medication Test

13. Many drugs are metabolized or eliminated via the liver or kidney. If a particular drug is nephrotoxic, what laboratory tests should be monitored for the safety of the patient? a. Na+, Cl-, K+

b. WBC c. Platelets d. Serum Creatinine

14. The liver usually metabolizes most drugs into compounds that are more easily excreted via the kidneys.Advancing age decreases both liver blood flow and levels of microsomal enzymes which decreases metabolism, causing the drug to accumulate to potentially high levels in the body. What laboratory values are used to monitor for hepatic function?

a. Albumin b. SGOT (AST) OR SGPTM (ALT) c. Total Bilirubin d. Total Protein

15. The nurse gives a patient’s routine medicines and the patient states, “I had fewer capsules than this yesterday. “Which of the following response is most appropriate?

a. “I am certain this dose is the amount the doctor feels is best.” b. “This is the number of capsules the doctor ordered.”

c. “ Let me recheck the doctor’s order.” d. “ Well, this is probably just a new order.”

16. You need to administer an unfamiliar medication. Which of the following are appropriate?

a. Look the medication up in the PDR b. Consult a nursing a drug book c. Consult the hospital pharmacist d. All of the above

17. You have just given a patient a dose of glipizide (glucotrol) 10 mg po. However you suddenly remember the physician’s new orders: D/C glucotrol; Humulin N 10 units q am. You forgot to D/C glucotrol on the MAR. You have already administered the glucotrol and Humulin N. What should your first response be? a. Complete an occurrence report b. Watch the patient closely for untoward symptoms c. Notify the attending physician immediately . d. Tell the patient you have given the wrong medication



Medication Test 18. Which of the following is not a medication error? a. Failure to give a drug within the prescribed time frame b. Failure to give a drug when you know it is contraindicated c. Giving the wrong drug to a patient d. Giving an unordered drug to a patient

. 19. Before administering the first dose of an IV antibiotic, the nurse should: a. Check the results of the WBC b. Tell the patient what side effects could occur c. Check the patient IV d. Determine if a culture and sensitivity has been ordered in order to make sure it is collected prior to starting the IV antibiotic 20. The most dangerous side effect of morphine sulfate is its: a. ability to disorient patients b. ability to induce sleep c. Check for a patent IV d. depressing effect on the respiratory center 21. The antihypertensive Tenormin (atenolol) 50mg q.d. has been previously ordered for a patient. Today the physician increased the order to 100 mg q.d. Which is the most appropriate action for the nurse before administering the medication?

a. monitor the patient ‘s PT/PTT b. monitor the I/O c. monitor the serum creatinine d. monitor the blood pressure

22. Two serious side effects of Gentamycin or Tobramycin a. Yeast and fungal infections b. Ototoxicity and nephrotoxicity c. Alopecia and epistaxis d. Leukopenia and thrombocytopenia 23. What drug is contraindicated for the patient receiving anticoagulant therapy? a. Phenergan b. Tylenol c. Aspirin

d. Demerol 24. When sodium warfarin (Coumadin) is given, the nurse should monitor the: a. I & O b. Prothrombin time (PT) c. Partial thromboplastin time (PTT) d. Serum Potassium



Medication Test

25. Laboratory values have indicated an overdosage of coumaddin in a patient. What drug is the antidote? a. Heparin b. Protamine sulfate c. Epogen d. Vitamin K

26. During administration of Heparin via an IV drip, which of the following labs may be ordered as frequently as q6 hrs?

a. H/H b. Partial thromboplastin time (PTT) c. Serum fribrinogen d. Sedimentation rate

27. Symptoms of digitals toxicity include:

a. abdominal pain; constipation; anorexia b. N/V; visual disturbances c. Tachypnea; hematuria d. Leg cramps; anorexia; drowsiness

28. Possible side effects from antineoplastic agents may include anorexia, nausea, vomiting and all of the

following EXCEPT: a. ↓ WBC b. ↓ Platelets c. ↓ H/H d. ↓ K+

29. All of the following laboratory abnormalities may occur after administration of furosemide (lasix).

Which is the most potentially dangerous? a. ↓ K+ b. ↓ Mg+2

c. ↓ Cl- d. ↓ Na+

30. In what disease is the administration of acetaminophen (Tylenol) contraindicated?

a. active peptic ulcer b. asthma c. deep vein thrombosis d. active Hepatitis C



Medication Test

31. A patient is receiving Humulin N 35 units each morning at 0730. At which of the times listed below is this person most at risk of a hypoglycemic reaction?

a. 9 a.m. b. 11 a.m. c. 3 p.m. d. 8 p.m.

32. Which of the following S/S in a diabetic patient could indicate a hypoglycemic reaction? a. fatigue & blurry vision b. irritable, shaky, & diaphoretic c. hungry, tired, & thirsty d. thirsty, hungry, & hypotensive

33. Which of the following insulin preparations could potentially cause a hypoglycemic reaction within

one hour?

a. Humulin N b. Humulin R c. Lispro (Humalog) d. Humulin 70/30

34. A patient is receiving Gentamycin 80 mg q 12 hrs. The patient is to receive the 4th dose today at 8 PM to infuse over 30 minutes. The physician has ordered peak and trough blood levels with the 4th dose. At which of these times should the peak blood level be drawn?

a. 7:30 PM b. 7:55 PM c. 8:35 PM d. 9:00 PM

35. A hypokalemic patient is receiving an infusion of NS containing 60 meq potassium chloride at 100 ml/hr. Which of the following is most appropriate for patient?

a. blood pressure readings q 1 hr b. deep tendon reflexes checked q 1 hr c. serum potassium levels q 1 hr d. continuous cardiac monitoring



Medication Test

36. Your patient is receiving IV therapy via a triple-lumen central line including: (1) total parenteral nutrition (TPN) at 75 ml/ Hr (2) an IV of NS at 20 ml/hr and (3) two antibiotics, one ordered q8hr and anthore q6 hr. Which of the following symptoms could suggest your patient has fluid overload?

a. wheezes b. urine output<30 ml/hr c. crackles in lower lobes d. S3 auscultated over the precordium

37. List the “ six rights” in administering medication?

Right________________ Right________________ Right________________ Right________________ Right________________ Right________________

38. Some oral medications may upset the stomach and should be given: a. Before meals on an empty stomach b. At least four hours after meals c. After meals on a full stomach d. At bedtime

39. When administering medications, the nurse assumes all of the following EXCEPT:

a. Being aware of the symptoms of overdosage b. Initially prescribing the correct dosage c. Knowing the expecting effects of the medication d. Knowing the route of administration

40. A patient is ordered Phenergan 10 mg IM. Phenergan is available in a vial of 25 mg/ml. How many

milliliters should be drawn up into the syringe? _________ml 41. Solumedrol 15 mg IV is ordered. A vial of Solumedrol contains 40 mg/ml? How many milliliters of Solumedrol will be drawn into the syringe? ________ml

42. The physician orders 0.2 g meprobamate (Equanil, Miltown) tabs. The dose on hand 400 mg tabs. How many tab(s) are given? _________ tab(s)



Medication Test

43. A 4000 g infant is experiencing adverse effects from the Demerol delivered before surgery to the mother. Naloxone (Narcan) 0.1 mg/kg is ordered? What dosage of naloxone will be administered? _______ mg 44. The physician orders Demerol 25 mg IM. On hand is an ampule of Demerol 75 mg in 2 ml. How many ml

are drawn into the syringe? _________ ml 45. The physician orders 8000 units of Heparin as an IV bolus. On hand is Heparin 10,000 USP units per 2 ml. How many ml of Heparin will you draw into the syringe?_________ ml 46. The physician has ordered a Heparin Bolus of 5,000 units IV followed by a heparin drip at 1,000 units per hour. The standard mixture of Heparin is 25,000 units/ 500 D5W. How many ml/hr should the pump be set to administer the Heparin drip. _________ ml/hr 47. A unit of packed cells (approximately 240ml) is to be administered over 4 hours. The blood tubing has a drop factor of 10 gtt/ml. Calculate the drip rate in gtt/min in order to administer the blood over 4 hours. __________ gtt/min 48. A new medication, X disodium, comes as a powder which must be reconstituted as follows: For Intravenous use: Add 24 ml of sterile water for injection, USP. Eash 2.5 ml of resulting solution contains 500 mg of X. prior to administration, dilute further to desired volume with an appropriate IV solution. How many ml must be injected into a 100 ml IV bag of NS to equal 105 g of X?___________ ml 49. Bonus: A procainamide drip is ordered for 2 mg/min. The standard mixture of procainamide is 2 g in 500

ml. At how many ml/hr should the IV pump be set? ___________ ml/hr

Name_______________________________ Unit_____________ Date______________



HIPAA Privacy Self-Study Materials This self-study packet serves as a review of important Health Insurance Portability and Accountability Act (HIPAA) requirements. Many of these requirements are included in our Code of Conduct and our Ethics and Compliance policies and procedures. Please read these materials and take the quiz that follows. You will need to return the quiz as instructed on the answer sheet after you complete it. If you have read these materials, you should have no trouble completing the quiz. The objectives of the HIPAA training are: • To heighten your awareness of and commitment to HIPAA regulations. • To reinforce the role you play in creating and maintaining organizational integrity, ethics, and compliance. • To renew your working understanding of HIPAA requirements. Missions and Values Statement By being familiar with the Mission and Values Statement and the stakeholder Commitments, each of us can contribute to maintaining our “Tradition of Caring.” Refer to page 4 of the Code and Conduct to review the Mission and Values Statement. • We have always endeavored to deliver healthcare compassionately and to maintain our strong ideals. • Our Mission and Values Statement is the cornerstone of our organization. It recognizes our commitment to deliver high quality, cost-effective healthcare in the communities we serve. It provides the value statement that we consider essential and timeless. The words selected from our Mission and Values Statement exemplify the type of conduct that all of us strive for. Reporting Concerns There will be no retribution for asking questions, raising concerns about the Code of Conduct or for reporting possible improper conduct that are done in good faith. Any colleague who deliberately makes a false accusation with the purpose of harming or retaliating against another colleague will be subject to punishment. We encourage the resolution of issues at the local lever whenever possible. To obtain guidance on an ethics or compliance issue or to report a potential violation, you may choose from several options: • Consult your supervisor • Consult your facility ECO or another member of management at your facility • Call the Ethics Line at 1-800-455-1996 The Ethics Line is an easy and anonymous way to report possible violations or obtain guidance on an ethics or compliance issue. You are encouraged to use the Line anytime, especially when it is inappropriate or uncomfortable to use one of the other methods. In order to properly investigate reports, it is important to provide enough information about your concern.



HIPAA Privacy Self-Study Materials Information Security Ids and Passwords Patient Financial Information, Clinical Information, and User Passwords are all examples of confidential information. A user ID without a password is not confidential and is frequently included in directories and other tools widely available. The person granting access to a system or application typically assigns a User ID to the end user, and the User ID is sometimes used for identification, tracking, and other maintenance procedures. If you have access to information systems, please keep in mind that your password acts as an individual key to our network and to critical patient care and business applications, and its must be kept confidential. It is part of your job to learn about and practice the many ways that you can help protect the confidentiality, integrity, and availability of electronic information assets. Confidential Information A patient’s diagnosis, the Company’s marketing strategy, and computer network configurations are all considered confidential information. The Confidentiality and Security Agreement states that individuals with access to confidential information will not disclose or discuss any confidential information even after termination of their relationship with Precise HealthCare Solutions. No Precise HealthCare Solutions Contractor, or other healthcare partner has a right to any patient information other than that necessary to perform his or her job. Although you may use confidential information to perform your function, it must not be shared with others unless the individuals have the need to know this information and have agreed to maintain the confidentiality of the information. Patient or confidential information should not be sent through our Intranet or the Internet until such time that its confidentiality could be assured. If it is necessary to send Patient information to a business associate, arrangements other than e-mail must be made. Privacy HIPAA and its implementing regulations set forth a number of requirements regarding ensuring the privacy of protected health information (PHI). HIPAA requires healthcare entities to appoint a facility privacy official (FPO). The FPO oversees and implements the Privacy Program and works to ensure the facility’s compliance with the requirements of the HIPAA Standards for Privacy of Individually Identifiable Health Information. The FPO is also responsible for receiving complaints about matters of patient privacy. HIPAA regulations do not prevent medial records from being maintained at the patient’s bedside or outside the patient’s room; however, they do encourage reasonable safeguards be put in place to protect the patient’s information from inappropriate uses or disclosures. The HIPAA regulations contain a number of restrictions on the transmission of health information; however, they do not prevent faxing or mailing health information as long as certain precautions are taken. The regulations mandate



HIPAA Privacy Self-Study Materials that health information may not be sold by a facility. The Notice of Privacy Practices must be made available to all patients, posted on the facility’s Internet site (unless the facility does not have a site) and the consent form language must refer to the notice. Patients do need to sign an acknowledgement form confirming receipt of the notice. Patients have the right to access any health information that has been used to make decisions about their healthcare at a facility. They can also access billing information. They may review the paper chart (supervised) or be provided a hard copy. Access to the Clinical Patient Care System (CPCS) is not a recommended method or providing access to health information. A patient may have access to all of the records in the designated record set. This record set includes any information that is maintained, collected, used or disseminated by a facility to make decisions about individuals. The paper record is the legal medical record and a copy should be provided upon request (electronic access is not appropriate with our current systems). A patient may be denied access under certain circumstances ( e.g., when a person may cause harm to him or herself or others, or when protected by peer review). The FPO has more information on the right to access. A patient may add an amendment to any accessible record for as long as the record is maintained by the facility. The request for amendment should be made in writing to the facility. The FPO and HIM department have more information on the right to amend. While patients have a right to amend their record that does not mean that health information can be deleted from the record. The patient may submit an addendum correcting or offering commentary on the record, but no information may be deleted from the record. In order for the HIM department to track releases of patient’s information, patients (including employees) should be directed to the appropriate personnel at the facility for access to any health information. Everyone is responsible for protecting patient’s individually identifiable health information. Any piece of paper that has individually identifiable health information on it must be disposed of in appropriate receptacles. The paper must be handled and destroyed securely. The elements that make information individually identifiable include: name, zip, or other geographic codes, Social Security Number, medical record/account number, health plan id, license number, vehicle identification number, and any other unique number or image. Any member of the workforce with a legitimate need to know to perform their job responsibilities may access a patient’s health information. However, the amount of information accessed should be limited to the minimum amount necessary to perform their job responsibilities. Policies prohibit employees from accessing their own records in CPCS (also known as Meditech). Typically, employees do not have a “need to know” for the performance of their job. Employees may, however, fill out the appropriate consent in HIM and can obtain a copy of their records. The hospital directory or listing of patients used by the PBX operator,



HIPAA Privacy Self-Study Materials information desk or volunteers should contain only patient name, room/location, and condition in general terms. Patient diagnosis or procedures should not be released. Also, this information may not be released about confidential patients or patients who ask not to be listed in the directory nor have their whereabouts known. Lists of patients may be provided to clergy. The current Conditions of Admission form explains that the patient name may be released to local religious organizations. The lists should consist of the patient name, room/location, and may include the condition in general terms. This list should be restricted by religion, and confidential patients; confidential information such as Social Security Numbers should not be included. Instructions: Please answer each question using the attached answer sheet HIPAA Privacy Self-Study Materials 1. What is a FPO? a. Facility Privacy Official b. Facility Police Officer 2. Confidential Information includes all of the following except: a. Patient Financial Information b. User ID c. Passwords d. Clinical Information 3. Individually identifiable health information may NOT be: a. Faxed b. Mailed c. Sold 4. Which of the following can you disclose after your relationship with the facility ends? a. Your Salary b. A patient’s diagnosis c. The company’s marketing strategy d. Computer network configurations



5. Who is responsible for protecting patient’s individually identifiable health information? a. CEO b. ECO c. Physician d. All of the above e. None of the above 6. It would be appropriate to release patient information to: a. The patient’s (non-attending) physician brother b. The transferring hospital’s personnel checking on the patient c. The respiratory therapy personnel doing an ordered procedure d. A retired physician who is a friend of the family 7. True or False: If a person has the ability to access facility or Company systems or applications, they have the right to view any information contained in that system or application? 8. True or False: Patient information may be attached within a company e-mail sent via the Internet to a business associate to resolve questions related to a patient’s account. 9. A patient listing that is given to a member of the clergy should be restricted by religion and may have the following information except: a. Patient name b. Patient social security number c. Patient location d. Patient condition in general terms. 10. Which of the following is the appropriate person with whom to share patient information even if the patient has NOT specifically authorized the release of information to the individual: a. A former physician of the patient who is concerned about the patient. b. A colleague who needs information about the patient to provide proper care c. A friend of the patient d. A pharmaceutical salesman who is offering a fee for a list of patients to whom he could send a free sample of his product.



HIPAA Privacy Self-Study Materials 11. The acronym for HIPAA stands for: a. Health Information Protection and Accountability Act b. Health Insurance Portability and Accountability Act c. Health Information Publication and Accumulation Act d. None of the above 12. Confidential Information must not be shared with another unless the recipient has: a. An OK from a doctor b. The need to know c. Permission from Human Resources d. All of the above 13. True or False: HIPAA privacy regulations prevent facilities from storing the medical record at the patient’s bedside. 14. True or False: It is part of our jobs to learn and practice the many ways we can help protect the confidentiality, integrity, and availability of electronic information assets. 15. True or False: Patients have a right to access their health information. 16. What is the standard for accessing patient information: a. A need to know for the performance of you job b. If a physician asks you the diagnosis of the patient c. Just because you are curious d. You are a relative of the patient 17. Yes or No: Can you access your own medical record via the Meditech system? 18. If an employee has a medical testing at an HCA facility, the appropriate way for him or her to access the test results is: a. Complete the release of information form in HIM and receive a copy of the results b. Check the computer system for his or her own results c. Get a fellow employee to access the results while looking over his or her shoulder d. Call a friend in the department where the test was done to get the results for the Employee



HIPAA Privacy Self-Study Materials 19. True or False: Patient or confidential information may be sent through Atlas or the Internet with guaranteed security. 20. Patient information is considered individually identifiable if which of the following Elements are included: a. Social security number b. Name c. Fingerprint d. All of the above 21. True or False: Patients do not need to sign a form acknowledging receipt of the facility’s Notice of Privacy Practices. 22. True or False: Only clinicians may access a patient’s health information. 23. Under the privacy rule each facility must designate ________________________ who is responsible for the development and implementation of privacy policies and procedures for the facility. a. A privacy official b. A HIPAA officer c. An ethics and compliance officer d. A mediator 24. A visitor who asks for a patient by name may receive the following information except: a. Patient name b. Patient condition in general terms (e.g. stable, critical, etc.) c. Patient location d. Patient diagnosis 25. True or False: Copies of patient information may be disclosed of in any garbage can in the facility.



HIPAA Privacy Self-Study Materials I certify that I have received HIPAA Awareness Training. I understand it represents mandatory policies of the organization and agree to abide by it. Signature___________________________________________________ Printed Name________________________________________________ Position__________________________________________________________ Agency__________________________________________________________ Social Security number______________________________________________ Date_____________________________________________________________



JCAHO & OSHA COMPETENCY ASSESSMENT Name______________________ ______ Title____________________ Date _________

1. Which of the following are patient’s rights?

A. The right to know the name, function and position of any hospital employee. B. The right to receive emergency care if needed C. The right to receive considerate and respectful care in a clean and safe environment, free from

unnecessary restraints. D. The right to refuse treatment E. All of the above

2. Measures to help calm a potentially violent person include the following except:

A. Give full attention to the person B. Position yourself for a safe exit C. Keep very close to the person D. Speak in a calm voice and be aware of your body language

3. The following information can be found on MSDS sheet:

A. How to clean up chemical spill B. First aid measures C. Exposure controls and personal protection D. All of the above

4. The most important method to prevent the spread of infection is:

A. Isolation procedures B. Ultraviolet light C. Adequate room ventilation D. Hand washing




5. Be sure that the medical equipment that you use:

A. Has a current inspection sticker placed by Clinical Engineering? B. Is in proper working condition C. Is taken out of service if not working properly labeled with the problem and sent for repair D. You have been train to use E. All of the above

6. When a disaster response is required, staff should:

A. Report to the parking garage B. Remove their ID’s C. Follow their department specific disaster response plan D. Use the telephone and elevators for non-emergency needs

7. A basic principal of Universal Precautions/ Universal Body Substance Precautions is:

A. To consider all body fluids potentially dangerous B. To wear gloves at all times C. To keep patient’s room doors closed at all time D. To pace all patients with infections in isolation.

8. If you experience a needle stick or other exposure to blood or body fluids, which of the following should be done?

A. Immediately cleanse the affected area. B. Report the exposure to the hospital’s employee health service and complete the appropriate

accident forms C. Notify your supervisor/manager D. Follow the procedure for blood/body fluid exposure E. All of the above

JCAHO & OSHA COMPETENCY ASSESSMENT



Name______________________ ______ Title____________________ Date _________

9. What should an employee who discovers a fire at work do second?

A. Rescue/remove anyone in immediate danger B. Alert others by activating the alarm C. Contain the fire D. Extinguish the fire

10. Which of the following is an example of an electrical hazard in the workplace?

A. Pulling electrical cords to unplug the equipment B. A frayed cord with exposed wires C. The combination of a mental bed frame, wet bedding and faulty wiring D. A and B only E. All of the above

11. Unless no alternative is feasible, contaminated needles and sharps shall Not be:

A. Recapped or removed B. Bent or broken C. Sheared D. All of the above

12. What step is missing from the following procedure for the operation of a fire extinguish? Break the

seal. Aim the hose at the base of the fire, squeeze the handle, Sweep.

A. Remove the cap B. Insert the pin C. Pull the pin D. Shake the container

13. Medical equipment brought in by an inpatient should:

A. Be switched as soon as possible to hospital equipment that the staff is trained to use. B. Be used throughout their hospital stay C. Be stored in Human Resources for safekeeping D. Be inspected by an outside vendor




Answer TRUE (T) /False (F) to the following Questions

14. (___) All trash from the Operating Room must be placed in red bags. 15. (___) Age specific guidelines means that patients are treated base upon their chronological age only.

16. (___) When lifting heavy objects, you should bend at the waist and raise the object up as you are standing up. This places the weight on muscles that are strongest for lifting.

17. (___) If a patient is coherent they do not need an advance directive.

18. (___) When caring for the geriatric patients, you should take into consideration that they may have short-term memory loss or visual acuity.

19. (___) Quality assurance and performance improvement are only the responsibilities of the hospital

personnel and not that of the agency or traveler nurse. 20. (___) Tuberculosis is an airborne disease that must be inhaled and is not easily transmitted.



AGE SPECIFIC TEST

Name__________________________ Date___________

1. _____ Autonomy vs. shame and doubt A. 18-29 Years Early Early Adulthood 2. _____ Cuddle and hug B. 30-59 Years Middle Adulthood 3. _____ Use dolls and puppets for explanation C. Birth to one year infancy of procedures. 4. _____ Increase in chronic health problems D. 60-Elderly Late Adulthood 5. _____ Accepts criticism or advise poorly E. 1-3 Years Toddle 6. _____ Provide finger food F. 3-6 Years Preschool Age 7. _____ Take steps to prevent falling G. 6-12 Years School Age 8. _____ Managing a household, rearing H. 12-18 Years adolescence Children developing a career 9. _____ Acceptance of one’s life, joy & limitations 10. ____ Achieving independence from parental control 11. ____ Accepting and stabilizing self-concept and body image 12. ____ Accepts role reversal with aging parents and preparing emotionally from their death 13. ____ Develops a personal view of death that prepares the individual for the final stages of life. 14. ____ Balancing work and other roles and prepares for retirement



Age Specific Test

Name__________________________ Date__________

15. Education for early adulthood would most likely include emphasis on:

A. Development of health lifestyle habits, problems related to sexuality, effects of alcohol, family planning, child care and home management

B. Adjustment to menopause C. Death and dying D. Chronic illness

16. Common health problems related to adulthood include:

A. Cardiovascular disease B. Cancer C. Acute and chronic respiratory disease D. All the above

17. The major cause of death in middle adulthood are:

A. Accidental B. Suicide C. Heart attack and stroke D. Homicide

True or False

18. _____ Balloons are appropriate toys for toddlers. 19. _____ Adolescents are prone to sports injuries. 20. _____ You should allow choices to all age groups when providing their care

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Precise HealthCare Solutions · Precise Healthcare Solutions Precise HealthCare Solutions 12/2005 Additional Information Have you been convicted of a felony that would prohibit your