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
    Vital Signs
    Normal Lab Values, cardiac enzymes,Troponin
    Use of Pulse Oximetry
    Emergency Defibrillation/ Cardioversion
    Electronic Documentation
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    EKG lead/Pad placement
    EKG Interpretation
    EKG Monitoring
    Use of Doppler
    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
    CARDIOVASCULAR
    Heart Sounds
    Coronary Anatomy and Circulation
    Conduction System
    CHF
    Ischemia
    Pulmonary Hypertension
    Systemic Hypertension
    Diseases of the Aorta
    STRESS TESTING WITH TREADMILL
    Preparation of Equipment
    Monitoring
    Complications
    HOLTER/EVENT MONITORS
    Preparation of Equipment
    Application of Leads
    Monitoring
    EQUIPMENT/INSTRUMENTATION
    Temporary Pacemakers
    Permanent Pacemakers
    Defibrillators