Infusion 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 *

Inpatient Acute Care Facility	123
Clinic/Ambulatory	123
Trauma Center	123
Post Acute Setting (long term care)	123
Other Setting (Hospice, Home Health)	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 *

Advanced directives	123
Awareness of HCAHPS	123
Accurate Patient Identification	123
Patient/family education	123
Computerized Documentation	123
Care of patient in Restraints	123
Lift/Transfer Devices	123
End of Life/Palliative Care	123
Bar Coding for medication administration	123
National Patient Safety Goals	123
Interpretation and communication of lab values	123
Medication Administration 5 Rights	123
Interpretation and communication of lab values	123
Collection of lab/specimens	123
Medication Reconciliation	123
Pain Assessment and management	123
Infection Control	123
Universal Precautions	123
Isolation Precautions	123
CPR/BLS	123
Minimize fall risks	123
Crash Cart	123
Defibrillator	123
Use proper body mechanics	123
Obtain Vital Signs	123
Ensures HIPPA compliance	123
Demonstrates knowledge of anatomy	123
Maintain Sterile Field	123

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 *

CADD Pump	123
Syringe Pump	123
Rate flow Regulator	123
Management of IV Infusion Pumps (Alaris, Baxter)	123
Management of elastomeric infusion	123
Pressurized Lines	123
Needless Systems	123
Curlin Pump	123
Blood Warmer	123
PCA Pumps	123
Computerized Charting	123
Automated Medication Dispensing Machines	123
Pulse oximetry	123
Use of Doppler/pulse checks	123
Automatic/manual Blood Pressure checks	123
Oxygen Delivery Device	123

ASSIST WITH INSERTION & MANAGEMENT OF:

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 *

Peripheral IV -Adult	123
Peripheral IV Child	123
Peripheral IV Neonate	123
Vein Selection- Peripheral IV’s	123
Interosseous Needles	123
Midline Catheter- Adult	123
Midline Catheter- Child	123
Indications for Midline/Picc Placement	123
Contraindications for Midline/Picc Placement	123
Proper vein selection	123
Measuring technique	123
Catheter and Introducer Device Selection	123
Correct Tip Placement	123
Insertion technique Basic Vein	123
Insertion technique Ultrasound	123
Insertion site preparation	123
Maintaining sterile field	123
Securement post placement	123
Xray assessment for tip location	123
Repositioning after Xray	123

CARE AND MAINTENANCE:

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 *

Peripheral IV	123
Scalp IV	123
Heparin/Saline Lock	123
Groshong PICC	123
Hickman/Broviac	123
Port A Catheter	123
Vascath	123
Multilumen catheter	123
Subclavian Line	123
IJ	123
Femoral Line	123
Power Picc	123
Power Port	123
Dressing Changes	123
Cap Changes	123
Line flushing maintenance (Frequency)	123

MEDICATION ADMINISTRATION:

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 *

Administer Chemotherapy	123
Lidocaine	123
TPN/Lipids	123
TPA (Alteplase)	123
Versed	123
Streptokinase	123
IVF	123
IV antibiotics	123
Blood and Blood products	123

TROUBLESHOOTING/COMPLICATIONS:

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 *

Air Embolism	123
Bleeding from site	123
Brachial Plexus Injury	123
Cardiac Arrythmia	123
Catheter Embolism	123
Catheter Related Sepsis	123
Catheter Tip Malposition or Retraction	123
Catheter Occlusion	123
Declotting Central Venous Lines	123
Declotting Hemodialysis Catheter	123
Declotting Implantable Port a Catheter	123
Declotting Groshong Central Line	123
Declotting Jugular Central Line	123
DeclottingSubclavian Central Line	123
Declotting PICC	123
Declotting Peripheral Site	123
Endocarditis	123
Extravasation	123
Hematoma	123
Myocardial Erosion	123
Perforation of Vessels	123
Phlebitis	123
Site Necrosis	123
Site Infection	123
Thromboembolism	123
Venous Thrombosis	123
Vessel Erosion	123

DISCONTINUATION OF IV THERAPY:

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 *

Peripheral IV	123
PICC/Midline	123
Central Lines	123

AGE SPECIFIC CHECKLIST:

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 yrs)	123
Preschool (ages 4-5 yrs)	123
School Age (ages 6-12 yrs)	123
Adolescent (ages 13-21 yrs)	123
Young Adult (ages 22-39)	123
Adult (ages 40-64)	123
Older Adult (ages 65+)	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. *