Please rate your experience / frequency within the last year

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)

MM slash DD slash YYYY

AGE OF CLIENTS:

Newborn/Neonate (birth to 30 days)(Required)
Infant (31 days to 12 months)(Required)
Toddler/Preschool (13 months to 5 years)(Required)
School Age Child/adolescent (6 years to 18 years)(Required)
Young Adults Middle Adult (19 years to 64 years)(Required)
Older Adults/Elderly (65+years)(Required)

GENERAL SKILLS

Standard Precautions(Required)
Isolation Precautions(Required)
Pediatric Respiratory/ Cardiac Arrest(Required)
Adult Respiratory/ Cardiac Arrest(Required)
Crash Carts(Required)
Defibrillators(Required)
Care of Patient in Restraints(Required)
Pain Management(Required)
Automated Med Dispensing Systems(Required)
Care Planning & Discharge Planning(Required)
Patient/Family Education(Required)
Electronic Documentation(Required)
Patient Head to Toe Assessment(Required)
Peripheral IV Insertion, Care and Maintenance(Required)

MEDICATIONS

Calculate mcg/min and mcg/kg/min(Required)
Titrating Medications(Required)
Isuprel(Required)
Adenosine(Required)
Amiodarone(Required)

ASSESSMENT AND MONITORING

Lead Placement(Required)
Basic 12 Lead EKG Interpretation(Required)
Cardiac Rhythm Interpretation(Required)
Doppler(Required)
Blood Pressure Invasive and Noninvasive(Required)

HEMODYNAMIC MONITORING

Art Line(Required)
Swan Ganz(Required)
Waveform Assessment(Required)
General Lab work Interpretation(Required)
ABG Interpretation(Required)
Cardiac Enzyme Interpretation(Required)
Chemistry Interpretation(Required)

CARE AND MAINTENANCE

Central Venous Access Device(Required)
Arterial Line(Required)
Swan Ganz(Required)
IABP(Required)
Sheaths(Required)
Removal of Sheath(Required)
Manual Pressure Hold(Required)
C-Clamp(Required)
FemStop(Required)
VasoSeal, Angioseal, PerClose(Required)
Hematoma Recognition/Management(Required)

PROCEDURE EQUIPMENT

Scrub EP Procedures(Required)
Circulate EP Procedures(Required)
Monitor EP Procedures(Required)
Ablation (Atrial/Ventricular)(Required)
Velocity Mapping(Required)
Cart/ Mapping(Required)
Rhythmia Mapping(Required)
Bloom Stimulator(Required)
Micropace Ep-4(Required)
Diagnostic Catheters(Required)
Bi-V(Required)
Stereotaxis(Required)
AICD Placement(Required)
Bovie(Required)
PPM(Required)
Baylis(Required)
Temporary Pacemaker(Required)
Peak Plasma Blade(Required)
Cardioversion(Required)
Internal Cardioversion Catheters / AICD Testing(Required)
NIPS Procedure(Required)
Pericardiocentesis(Required)
Demonstrate Proper Preservations of Tissue Specimen for Lead Extractions(Required)
ACT Machine(Required)
Lead Extractions – Spectranetics laser(Required)
Device Implants(Required)
Ablation Equipment (ie: Stockert, Maestro, Cool Flow, Tactisys)(Required)

OTHER SKILLS