EP Tech Skills Checklist

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Today's Date: * +

First Name: *

Last Name: *

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EXPERIENCES WITH AGES

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2 )Limited Experience

3) Experienced

4 )Very Experienced

*

Newborn/Neonate (birth to 30 days)	1234
Infant (1 month to 1 year)	1234
Toddler (1 year to 3 years)	1234
Preschooler (3 years to 5 years)	1234
School Age Child (5 years to 12 years)	1234
Adolescents (12 years to 18 years)	1234
Young Adults (18 years to 39 years)	1234
Middle Adults (39 years to 64 years)	1234
Older Adults (64 years to 79 years)	1234
Elderly Adults (over 79+ years)	1234

GENERAL SKILLS

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2) Limited Experience

3) Experienced

4) Very Experienced

*

Standard Precautions	1234
Isolation Precautions	1234
Pediatric Respiratory/Cardiac Arrest	1234
Adult Respiratory/Cardiac Arrest	1234
Crash Carts	1234
Defibrillators	1234
Care of Patient in Restraints	1234
Pain Management	1234
Automated Med Dispensing Systems	1234
Care Planning & Discharge Planning	1234
Patient/Family Education	1234
Electronic Documentation	1234
Patient Head to Toe Assessment	1234
Peripheral IV Insertion, Care and Maintenance	1234

MEDICATIONS

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2) Limited Experience

3) Experienced

4) Very Experienced

*

Calculate mcg/min and mcg/kg/min	1234
Titrating Medications	1234
Isuprel	1234
Adenosine	1234
Amiodarone	1234

ASSESSMENT AND MONITORING

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2) Limited Experience

3) Experienced

4) Very Experienced

*

Lead Placement	1234
Basic 12 Lead EKG Interpretation	1234
Cardiac Rhythm Interpretation	1234
Doppler	1234
Blood Pressure Invasive and Noninvasive	1234

HEMODYNAMIC MONITORING

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2) Limited Experience

3) Experienced

4) Very Experienced

*

Art Line	1234
Swan Ganz	1234
Waveform Assessment	1234
General Lab Work Interpretation	1234
ABG Interpretation	1234
Cardiac Enzyme Interpretation	1234
Chemistry Interpretation	1234

CARE AND MAINTENANCE

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2) Limited Experience

3) Experienced

4) Very Experienced

*

Central Venous Access Device	1234
Arterial Line	1234
Swan Ganz	1234
IABP	1234
Sheaths	1234
Removal of Sheath	1234
Manual Pressure Hold	1234
C-Clamp	1234
FemStop	1234
VasoSeal, Angioseal, PerClose	1234
Hematoma Recognition/Management	1234

PROCEDURE EQUIPMENT

Rank each of the following sections on a scale of 1 to 4:

1) No Experience

2) Limited Experience

3) Experienced

4) Very Experienced

*

Scrub EP Procedures	1234
Circulate EP Procedures	1234
Monitor EP Procedures	1234
Ablation (Atrial/Ventricular)	1234
Velocity Mapping	1234
Cart/Mapping	1234
Rhythmia Mapping	1234
Bloom Stimulator	1234
Micropace EP-4	1234
Diagnostic Catheters	1234
Bi-V	1234
Stereotaxis	1234
AICD Placement	1234
Bovie	1234
PPM	1234
Baylis	1234
Temporary Pacemaker	1234
Peak Plasma Blade	1234
Cardioversion	1234
Internal Cardioversion Catheters/AICD Testing	1234
NIPS Procedure	1234
Pericardiocentesis	1234
Demonstrate Proper Preservations of Tissue Specimen for Lead Extractions	1234
ACT Machine	1234
Lead Extractions - Spectranetics laser	1234
Device Implants	1234
Ablation Equipment (ie: Stockert, Maestro, Cool Flow, Tactisys)	1234

Attestation

ATTESTATION: *

I certify that the information provided 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. *