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 AdultsMiddle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Care of Patient in Restraints
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Cardiac Monitoring/Interpretation
    Titration of drips
    Administration of Blood/Blood Products
    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
    MEDICATION ADMINISTRATION
    Moderate/Conscious Sedation
    Sedation Reversal Agents
    Contrast Medium
    Antiemetics
    Narcotic Pain Medications
    PRE-PROCEDURE
    Allen Test
    Doppler
    EKG lead/pad placement
    Blood Pressure Invasive and NonInvasive
    HEMODYNAMIC MONITORING
    Art Line
    Swan Ganz
    Waveform Assessment
    CARE AND MAINTENANCE OF
    Arterial Line
    Swan Ganz
    IABP
    Sheath/Removal of Sheath
    MEDICATIONS
    Calculate mcg/min and mcg/kg/min
    Diprovan (Propofol)
    Esmolol (Brevibloc)
    Diltiazem HCL (Cardizem)
    Digoxin (Lanoxin)
    Nitroglycerin (SL,IV,IC)
    Adenocard (Adenosine)
    Amiodarone (Cordarone)
    Corvert (Ibutilide)
    Heparin
    CARDIOVASCULAR
    Hematoma Recognition/Management
    Radial, brachial, femoral, pedal pulse checks
    Assessment of heart sounds
    General labwork/cardiac enzyme interpretation
    ABG Interpretation
    Coagulation Interpretation
    PULMONARY
    Set up Oxygen Delivery Devices(Cannula, NRBM, Ambu)
    Assist with Intubation
    Suction equipment (oral,NP, In line)
    Assessment of breath sounds
    NEUROLOGICAL
    Identify Sudden Change in LOC
    Assess Sensory, Motor, Speech Function,Gag reflex
    Glasgow Coma Scale
    PROCEDURES DIAGNOSTIC AND INTERVENTIONAL
    Panning Table
    Moving Image Intensifier, Knowledge of views ( RAO,LAO, cranial, caudal)
    Scrub EP Procedures
    Circulate EP Procedures
    Ablation ( Atrial/Ventricular)
    Cartomapping
    Bloom Stimulator
    Diagnostic Catheters-BI-B
    Sterotaxis
    AICD Placement
    PPM
    NIPS Procedure
    Pericardiocentesis
    Demonstrate proper preservation of tissue for lead extraction
    Cardioversion
    PACEMAKERS
    Permanent Pacemaker/AICD
    Temporary Epicardial/Transthoracic Pacing
    Temporary External /transvenous pacing
    CARE OF PATIENT DURING EMERGENCY PROCEDURES
    Emergency Defibrillation/ Cardioversion
    Anaphylaxis
    Pneumothorax
    EQUIPMENT/SUPPLIES
    ACT Machine
    Device implants
    Manual Pressure Hold
    Femostop/ C-Clamp
    VasoSeal, Angioseal, PerClose