Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
    		•
    AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Hospital Experience
    Clinic Experience
    Teaching/Educational Facility
    Vital Signs
    Care of patients in restraints
    Use of transfer/lifting devices
    Care of patients in isolation
    National Patient Safety Goals
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    IV Pumps
    Other IV Pumps:
    Electronic Documentation
    CT
    Venipuncture
    Upper extremities
    Lower extremities
    Upper extremities with contrast
    Lower extremities with contrast
    RF Ablations with CT
    CT Guided Drainage
    Adrenal
    Appendix
    Aortic Dissection
    Aortic Aneurysm
    Pediatric CT Exams
    Abdomen
    Biopsy
    Brain without contrast
    Brain with Contrast
    Cervical Spine
    Circle of Willis
    CTA
    Chest
    Facial Bones/Maxillofacial
    GI tract
    IAC
    Injection
    Joint Studies ( Hip, knee ankle)
    Larynx
    Liver
    Lumbar spine
    Lung Biopsy
    Pancreas
    Pelvis
    Pulmonary Embolism study
    Radiation Therapy
    RFA
    Soft Tissue Neck
    Spleen
    Trauma Patients
    TM Joints
    3D Imaging
    Smart Prep
    Smart View
    MRI
    Gradient Echo Imaging
    Muliplanar Reconstruction
    Partial Saturation Images
    Spin Echo Images
    Surface Coils
    T-1 Weighted Images
    T-2 Weighted Images
    Open
    Closed
    Brain
    Extremities
    Injections
    Spine
    RADIOLOGY
    Abdomen
    Arthrograms
    Bone Density
    Chest
    ER Exams
    GI Series
    Hip
    Hysterosalpingogram
    OR Exams
    PACS System
    Portable Exams
    Renal Tomography
    Soft Tissue Studies
    Trauma Exams
    Urethrography
    Extremities:
    Pelvic/Obliques/Judet Views
    Pelvic Sacrum/Coccyx
    Pelvic SI Joints
    Upper/Lower
    Skull:
    Facial
    Mandible
    Orbits
    Sinus Series
    Spine:
    Cervical Spine
    Cervical Spine-Obls/Flexion/Extension
    Lumbar spine
    Lumbar Spine-Obls/Flexion/Extension
    Thoracic Spine
    Thoracic Spine-Swimmer's View
    MAMMOGRAPHY
    Bilateral Mammogram
    Density Settings
    Digital Mammography
    Implants
    Irradiated Breasts
    Male Breast Scan
    Mammography Quality Standards Act
    Needle Aspiration
    Needle Localization
    Optical Breast Screening
    Post Partum Mastitis
    Reduction Mammoplasty
    Specimen Radiographs
    Spot Compression View
    Stereotactic Core Biopsy
    Self Breast Exams
    FLUOROSCOPY
    Angiogram
    Arteriogram
    Barium Enema
    Bronchogram
    ERCP
    Esophagram
    Gallbladder
    Myelogram
    Sialogram
    Small Bowel Follow Through
    Small Bowel Series
    Tomogram
    T-Tube Cholangiogram
    Upper GI Series-Air Contrast
    Upper GI Series-Single Contrast
    Venograms
    Voiding Cystogram
    Barium Swallow:
    Modified Barium Swallow/Protocol Swallow
    Swallow Studies with Videotaping
    C-Arm Use:
    Mobile C-Arm Bronchoscopy with Fluoro Guidance
    IVP:
    IVP with Tomograms
    EQUIPMENT
    GE
    Philips
    Siemens
    Toshiba
    PACS System
    RIS-Cerner
    MYELOGRAMS
    Cervical Spine
    Lumbar Spine
    Thoracic Spine
    OR CASES
    Cystography
    Extremity Studies
    Hip Studies
    Operative Cholangiography
    Retrograde Urography
    Spine Work
    Sterile Procedures in OR
    ENEMA STUDIES
    Sterile Procedures in OR
    Barium Enema-Single Contrast
    Water Soluble Contrast Enema
    Barium Enema-Air Contrast
    Lower GI Studies thru Colostomy