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
    Care of Patient in Restraints
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    PCA/Epidural pumps
    Administration of Blood/Blood Products
    Assessment of heart/lung sounds
    Assessment of bowel sounds
    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
    Antibiotics IM/IV
    Contrast Medium
    Antiemetics
    Narcotic Pain Medications
    PRE-PROCEDURE
    EKG Lead Placement
    Interpretation of Pre-Procedure Labs
    Set up of Scopes and Video Equipment
    PROCEDURES/EQUIPMENT
    Enteroscopy
    EGD/Gastroscopy
    Endoscopic Ultrasound
    Active GI Bleed
    Cautery Devices
    Variceal Banding, Gold Probe
    Esophageal Dilatations(balloons, Maloney,Savory)
    Esophageal Motility Tests
    Esophageal Monometry Studies
    Sclero Therapy
    HALO
    Colonoscopy
    Flexible Sigmoidoscopy
    Liver Biopsy
    Polypectomy
    ERCP
    Gastrostomy tube/button or PEG Placement
    Pediatric PEG
    Video Capsule Endoscopy
    Stretta
    pH Probe 24 Hour Study
    Foreign Body Aspiration/Retrieval
    POST-PROCEDURE
    Sedation Recovery Scales
    Assess for Gag Reflex
    Adbominal assessement, bowel sounds
    Proper use of scope washers/Leak testers
    Abdominal pain, recognizing s/sx of possible perforation