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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

General Skills Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Advanced directives
Awareness of HCAHPS
Patient / family teaching
Lift / transfer devices
Specialty beds
Restrictive devices (restraints)
End of life care / palliative care
Wound assessment & care
Automated Medication Dispensing System, Pyxis, Omnicell, or other
Bar coding for medication administration
Diabetic care & education
Blood Glucose Monitoring (BGM)
Insulin administration
National Patient Safety Goals
Accurate patient identification
Effective communication
Interpretation & communication of lab values
Medication administration
Labeling (medications & specimens)
Medication reconciliation
Anticoagulation therapy
Pain assessment & management
Monitoring conscious sedation
Infection control
Universal precautions
Isolation
Minimize risk for falls
Prevention of pressure ulcers
Universal protocol (site / side verification)
Normothermia
Beat blocker (preop)
Anesthesia: General Knowledge Experience
Moderate sedation / protocols & procedures
Local anesthetics
Regional blocks (intrathecal / epidural / spinal)
General anesthesia (IV anesthetic agents / inhalation anesthesia agents)
Administer & monitor paralytic agents
Administer & monitor reversal agents
Assessment of dermatomes
Neuromuscular blocking agents (depolarizing, non- depolarizing, reversal agents)
Benzodiazepines / reversal
Opioids / reversal
Pulmonary Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Assessment of breath sounds / rate / effort
Airway Management, Care & Maintenance
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Head positioning to ensure airway patency
Oral / NT airway
Laryngeal Mask Airway (LMA)
Endotracheal tube
Tracheostomy
Use of ambu bag
O2 therapy (NC / mask)
Use of CO2 monitoring devices
SVO2 monitoring
Oral / NT suctioning
Assisting with intubation
Assisting with extubation
Measuring tidal volume
Arterial blood gas interpretation / analysis
Obtaining ABG blood sample (art line, arterial puncture)
Pulse oximetry
Mechanical ventilation
Pleural chest tubes
Postoperative Care (Respiratory)
(1) Limited or no experience
(2) Experienced, but may need review or
supervision
(3) Able to function independently *
 123
Tracheostomy
Laryngeal procedures / laryngectomy
Lung transplant
Video- assisted thoracoscopic surgery (VATS)
Radical neck dissection
Penetrating/open chest trauma
Sinus surgery
Adeno- tonsillectomy (T&A)
Thoracotomy / lobectomy / pneumonectomy
Cardiovascular Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Cardiovascular assessment
Interpretation of arrhythmias
Performing 12 lead EKG's
Care of patient with VAD (ventricular assist device)
Set Up & Interpretation of:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Hemodynamic monitoring (CVC / aline / PA catheter)
External / temporary pacemaker
Cardiac arrest / CPR
Cardioversion / defibrillation
Postoperative Care (Cardiovascular)
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Permanent pacemaker / AICD insertion
Vascular bypass / grafting
Embolectomy / thrombectomy
Abdominal aortic aneurysm (AAA) repair
Thoracic aortic aneurysm repair
Endoluminal stenting
Vena cava filter
Postoperative myocardial infarction
Neurology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Baseline neurological assessment
Glasgow coma scale
Cranial nerve assessment
Seizure precautions
Cervical spine precautions
Postoperative Care (Neuro Surgery)
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Craniotomy
Burr holes
Aneurysm clipping / coiling
Evacuation of hematoma (subdural, epidural)
Carotid endarterectomy
Intracranial tumor excision
Spinal tumor excision
Laminectomy
Spinal fusion
Ventricular peritoneal shunt
Tether Cords
Set Up & Care of Intracranial/Cerebral Perfusion Pressure Monitoring (ICP/CPP) via:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Ventriculostomy
Subarachnoid screw / bolt
Gastrointestinal Experience - Care of Patient with:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Gastric tubes (NG/G)
Jejunostomy tube
Assessment & management of wound drains (self- suction / irrigation / drainage)
Endoscopic procedures
Postoperative Care (GI)
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Laparoscopic
Exploratory laparotomy
Nissen fundoplication
Esophageal procedures
Abdominal trauma
Gastroplasty / bypass (bariatric surgery)
Gastrectomy (partial / complete)
Whipple procedure
Pyloroplasty
Vagotomy
Appendectomy
Bowel / colon resection
Colostomy / ileostomy
Hernia repair
Endocrine Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Transphenoidal hypophysectomy
Adrenalectomy
Thyroidectomy
Parathyroidectomy
Intravenous Management Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Starting peripheral IV's
Care of patient with peripherally- inserted central catheter (PICC) Groshong / Hickman
Administration of blood / blood products
Autotransfusion of blood / blood products
Administration of volume expanders (albumin, dextran, etc)
Miscellaneous Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Aldrette scoring
Experience with level 1 trauma patients
Management of patient with malignant hyperthermia
Anaphylaxis
Care of patients with latex allergies
Phlebotomy: peripheral
Drawing blood from invasive lines
Pharmacology - Use & Administration of:
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
H2 receptor antagonists: (Zantac, Pepcid, Carafate)
Antiemetics (Zofran, Phenergan, Reglan)
Steroids: (decadron, Solu-Medrol)
Emergency meds (ACLS protocols)
Anticonvulsants: (Dilantin, phenobarbital)
Inotropes / vasoactive drips
Calcium channel blockers: (Cardizem)
Antihypertensives: (nipride)
Antiarrhythimics: (amiodarone, lidocaine, procan)
Diuretics: (Lasix, edecrin sodium, Bumex)
Fibrinolytics
Glycoprotein IIb / IIIa receptor inhibitors: (Integrilin, Aggrastat)
Nebulizer treatments: (Ventolin, Atrovent, racemic, ephinephrine)
Other Procedures
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Post orthopedic / musculoskeletal procedures
Post ENT procedures
Post breast procedures (mastectomy / lumpectomy)
Post GYN procedures
Post prostate procedures
Post wound care (I&D / debridement)
Age Specific Competencies Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Newborn / neonate (birth-30 days)
Infant (31 days-1 year)
Toddler (2-3 years)
Preschool (ages 4-5 years)
School age (ages 6-12 years)
Adolescents (ages 13-21 years)
Young adult (ages 22-39 years)
Adults (ages 40-64 years)
Older adult (ages 65-79 years)
Elderly (ages 80+ years)
ATTESTATION *