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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 *
Advanced directives123
Patient/family teaching123
Restrictive devices (restraints)123
Lift/transfer devices123
Specialty beds123
End of life care/palliative care123
Automated Medication Dispensing System, Pyxis, Omnicell, or other123
Bar coding for medication administration123
Checks & marks distal pulses123
Performs allen test123
MEDICATION ADMINISTRATION *
Emergency meds (ACLS)123
Antiarrthymics123
Antibiotics123
Antihistamines123
Beta blockers123
Nitrates123
Vasopressors123
Thrombolytics123
Contrast medium123
PRE-PROCEDURE *
Completion of pre-procedure checklist123
Skin prep & shave123
Lead placements123
POST-PROCEDURE *
Monitoring (procedure specific & documentation)123
Sedation recovery scale (facility specific)123
Maintain & monitor A/V sheaths123
Set up & maintain arterial catheters123
Set up & maintain Swanz Ganz catheter123
GENERAL SKILLS - EXPERIENCE *
Obtain & monitor ACT123
Removal of A/V sheaths123
Manual pressure hold123
Application & monitoring of vascular closure devices123
Assists with IABP insertion123
Manages IABP123
Radiation safety123
National Patient Safety Goals123
Accurate patient identification123
Effective communication123
Interpretation & communication of lab values123
Medication administration123
Labeling123
Anticoagulation therapy123
Reconciliation123
Monitoring conscious sedation123
Pain assessment & management123
Use of PCA (IV, intrathecal, epidural)123
Infection control123
Universal precautions123
Isolation123
Minimize risk for falls123
Prevention of pressure ulcers123
Wound care123
CARDIAC MONITORING & EMERGENCY CARE *
Obtains 12 lead EKG123
Interpretation of rhythm strips123
Treatment of dysrythmias123
Use of rapid response teams123
Cardiac arrest/CPR123
O2 therapy & delivery123
Ventilator management123
Pulse oximetry123
Use of doppler123
IV THERAPY *
Starting & maintaining peripheral IVs123
Blood draw: venous123
Central line care123
Blood draw: central line123
GENERAL SKILLS - CONT EXPERIENCE *
Care & management of ports123
Care & management of PICC / Groshong / Hickman123
TPN & lipids123
Administration of blood/blood products123
Administration of chemotherapy123
Monitoring chemotherapy (does not initiate)123
Endometriosis123
OTHER *
Diabetes mellitus123
Blood Glucose Monitoring (BGM)123
Insulin administration123
Awareness of HCAHPS123
INTERVENTIONAL RADIOLOGY (RN) EXPERIENCE *
Circulates for interventional procedures123
Scrubs for interventional procedures123
Angiogram / aortogram123
Angioplasty123
Vascular stenting123
Declotting123
Embolization123
TIPS123
Port placement123
Dialysis catheter placement123
Retrieval of foreign body123
UAE (Uterine Arterial Embolization)123
EVLT (Endovascular Laser Therapy)123
Vertebro / kyphoplasty123
Neuroradiology123
Discogram123
AGE-SPECIFIC CHECKLIST *
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 *