Cath Lab Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently   *

Procedural Cath Lab	123
Interventional Cath Lab	123
Interventional Radiology	123
Pre/Post Setting	123
EP Lab	123

GENERAL SKILLS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Experienced in diagnostic catheterizations	123
Experienced in interventional catheterizations	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Awareness of HCAHPS	123

GENERAL SKILLS - PHYSIOLOGIC MONITORING:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Monitoring / recording of LHC/RHC	123
Monitoring / recording of aortic / mitral valve cases	123
Monitoring / recording of PCI (Percutaneous Coronary Interventions)	123
Monitoring / recording valve cases	123
Monitoring / recording ASD closures	123
Monitoring / recording of EP / ablation cases	123
Monitoring / recording of permanent pacemaker insertions	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Medication reconciliation	123
Labeling (medications & specimens)	123
Anticoagulation therapy	123
Monitoring conscious sedation	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123
Use of rapid response teams	123

GENERAL SKILLS - CIRCULATES:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

LHC/RHC	123
IABP insertions	123
FFR (radi wire)	123
IVUS/volcano	123
Thrombectomies	123
Valvuloplasty	123
ASD closures	123
Atherectomy	123
Filter wires	123
Embolic protection devices	123
EP/ablations	123
Permanent pacemaker insertions	123
Places leads & pads for cardiac mapping	123
Electronic charting	123
Time Out Protocol	123

GENERAL SKILLS - SCRUBS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

LHC/RHC	123
IABP insertions	123
Filter wires	123
Embolic protection devices	123
ASD closures	123
Valvuloplasty	123
Atherectomy	123
PCI	123
EP/ablations	123
Permanent pacemaker insertions	123
Maintain temporary pacemaker	123

GENERAL SKILLS - EQUIPMENT:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Hemochron	123
ABG analysis machines	123
Laser	123
Power injectors	123

INTERVENTIONAL RADIOLOGY RN EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Circulates for interventional procedures	123
Scrubs for interventional procedures	123
Angiogram / aortogram	123
Angioplasty	123
Vascular stenting	123
Declotting	123
Embolization	123
TIPS	123
Port placement	123
Dialysis catheter placement	123
Retrieval of foreign body	123
UAE (Uterine Arterial Embolization)	123
EVLT (Endovascular Laser Therapy)	123
Vertebro / kyphoplasty	123
Neuroradiology	123
Discogram	123
AAA endograft repair	123
Carotids	123
Extremities	123

AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Newborn / neonate (birth-30 days)	123
Infant (31 days-1 year)	123
Toddler (ages 2-3 years)	123
Preschool (ages 4-5 years)	123
School age (ages 6-12 years)	123
Adolescent (ages 13-21 years)	123
Young adult (ages 22-39 years)	123
Adult (ages 40-64 years)	123
Older adult (ages 65-79 years)	123
Elderly (ages 80+ years)	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *