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
    Lifting/Transferring Devices
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    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
    PRE-PROCEDURE
    Allen Test
    Doppler
    EKG lead/pad placement
    Blood Pressure Invasive and Noninvasive
    HEMODYNAMIC MONITORING
    Monitoring/Recording cases
    Waveform Assessment
    Coagulation Interpretation
    CARDIOVASCULAR
    Hematoma Recognition/Management
    Radial, brachial, femoral, pedal pulse checks
    PULMONARY
    Set up Oxygen Delivery Devices(Cannula, NRBM, Ambu)
    Assist with Intubation
    Suction equipment (oral,NP, In line)
    PROCEDURES DIAGNOSTIC AND INTERVENTIONAL
    Panning Table
    Moving Image Intensifier, Knowledge of views( RAO, LAO, cranial, caudal)
    Scrub Diagnostic Procedures
    Scrub Interventional Procedures
    Specimen Radiographs
    Selective Radiographs
    TIPPS Procedure
    Angioplasty/Stent
    Thrombolysis/Thrombectomy
    Embolic Protection Devices
    Cerebral Coiling
    PVA
    Gelfoam
    Cerebral Angiography
    Carotid Arteriogram
    Brachial Arteriogram
    Aortogram
    Femoral Arteriogram
    Renal Arteriogram
    Pulmonary Arteriogram
    Venogram
    Endografts
    AV Fistulas
    PACEMAKERS
    Permanent Pacemaker/AICD
    Temporary Epicardial/Transthoracic Pacing
    Temporary External /transvenous pacing
    CARE OF PATIENT DURING EMERGENCY PROCEDURES
    Emergency Defibrillation/ Cardioversion
    Anaphylaxis
    Vasovagal Response
    Pneumothorax
    Cardiogenic Shock
    Embolism
    Cardiac/Respiratory arrest
    EQUIPMENT/SUPPLIES
    ACT Machine
    Hemochron
    Power Injectors
    Manual Pressure Hold
    Femostop/ C-Clamp
    VasoSeal, Angioseal, PerClose
    OTHER SKILLS (Please list)
    Please list other skills: