Vascular Interventional Technologist Skills Checklist

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Today's Date: * +

First Name: *

Last Name: *

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GENERAL SKILLS 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 *

Advanced directives	123
Supervisory or Charge experience	123
National Patient Safety Goals/Core Measures	123
Awareness of HCAHPS	123
Accurate Patient Identification	123
Maintain Sterile Field	123
Use proper body mechanics	123
Use of transfer/lifting Devices	123
Infection Control	123
Universal Precautions	123
Isolation Precautions	123
Minimize fall risks	123
Crash Cart	123
Defibrillator	123
Care of patient in Restraints	123
Obtain Vital Signs	123
Patient /Family education	123
Electronic Documentation	123
Ensures HIPAA compliance	123
Quality control of equipment	123
Diagnostic Criteria Quality	123
Image annotation	123
Flow Studies	123
Transducer Selection	123
Disinfection of equipment	123
Photoplethysmography	123

IV 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 *

IV insertion	123
Maintenance of IV	123
Use of contrast agents	123

VASCULAR PROCEDURES:

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 *

Carotid Artery	123
Subclavian artery	123
Vertebral artery	123
Arterial peripheral upper extremity	123
Arterial peripheral lower extremity	123
Arterial Graft Duplex	123
Venous peripheral upper extremity	123
Venous peripheral lower extremity	123
Duplex	123
Color Doppler	123
Carotid Doppler	123
M Mode	123
Real Time	123

ECHOCARDIOGRAPHY:

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 *

EKG	123
TEE (transesophageal esophagography)	123
Adult echocardiogram	123
Pediatric echocardiogram	123
Stress Echo	123
Doppler	123
Dobutamine stress echocardiogram	123
Color Flow	123
M-Mode	123
Real Time	123

DOCUMENTATION:

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 *

Allscripts	123
Cerner	123
Epic	123
Meditech	123
McKesson	123
PACS	123

WORK SETTING:

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 *

Acute Hospital Setting	123
Large/Regional Teaching Facility	123
Outpatient Clinic	123

CERTIFICATIONS/LICENSURE/REGISTRATIONS:

Rank each of the following sections on a scale of 1(Yes) to 2(No):
1) Yes
2) No *

BLS	12
ACLS	12
PALS	12
ARRT	12

IR PROCEDURES (PREPARE):

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 *

Cerebral Angiogram	123
Lower Extremity Angiogram	123
Upper Extremity Angiogram	123
Ultrasound Guided Biopsy	123
CT Scan Guided Biopsy	123
Liver Biopsy & Embolization	123
Line Placement - Broviac	123
Line Placement - Groshong	123
Line Placement - Hickman	123
Line Placement - PICC	123
Line Placement - PortaCath	123
Uterine Fibroid Embolization	123
Temp Hemodialysis Shunt Placement	123
Perm Hemodialysis Shunt Placement	123
AV Fistula/Shunt Declotting	123
Vertebroplasty	123
Lumbar Puncture	123
Myelogram	123

IR PROCEDURES (ASSIST):

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 *

Cerebral Angiogram	123
Lower Extremity Angiogram	123
Upper Extremity Angiogram	123
Ultrasound Guided Biopsy	123
CT Scan Guided Biopsy	123
Liver Biopsy & Embolization	123
Line Placement - Broviac	123
Line Placement - Groshong	123
Line Placement - Hickman	123
Line Placement - PICC	123
Line Placement - PortaCath	123
Uterine Fibroid Embolization	123
Temp Hemodialysis Shunt Placement	123
Perm Hemodialysis Shunt Placement	123
AV Fistula/Shunt Declotting	123
Vertebroplasty	123
Lumbar Puncture	123
Myelogram	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. *