Emergency Room 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
Trauma Center	123
Academic/Teaching Facility	123
Outpatient Care Facility	123
Long term care/Skilled Nursing	123
Clinic/Ambulatory	123
Home Health Setting	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
HIPAA	123
Patient/family teaching	123
Restrictive devices (restraints)	123
Lift/transfer devices	123
Specialty beds	123
End of life care/palliative care	123
Post mortem care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Bar coding for medication administration	123
Triage	123
Organ donor protocols	123
Consent for treatment of a minor	123
Procedure for a patient signing out AMA	123
Knowledge of cobra criteria/transfer patients	123
Disaster protocols	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Labeling	123
Anticoagulation therapy	123
Medication reconciliation	123
Monitoring conscious sedation	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Awareness of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)	123
Prevention of pressure ulcers	123
Wound care	123
Suture tray set up	123

CARDIAC MONITORING & EMERGENCY CARE:

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 *

Obtains 12 lead EKG	123
Interpretation of rhythm strips	123
Treatment of dysrythmias	123
Use of rapid response teams	123
Cardiac arrest/CPR	123
Code cart set up and shift checks	123
O2 therapy & delivery	123
Pulse oximetry	123
Use of doppler	123

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 *

Starting & maintaining peripheral IVs	123
Blood draw: venous	123
Central line care	123
Blood draw: central line	123
Care & management of ports	123
Care & management of PICC /Groshong / Hickman	123
Administration of blood / blood products	123
Diabetes mellitus	123
Blood Glucose Monitoring (BGM)	123
Insulin administration	123

TRAUMA 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 *

Trauma score	123
Critical transports	123
Air transport (helicopter or jet)	123
Other transport experience	123
Level 1 trauma	123
Level 2 trauma	123
Level 1 infuser	123
Open chest massage	123
Peritoneal lavage	123
Hypovolemic shock	123
H+H / stat lab test machine	123
Post drowning	123
Auto transfuser / warmer	123

BURN 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 *

First degree	123
Second degree	123
Third degree	123
Electrocution	123
Hazardous material exposure / contamination	123
Calculation of total Body Surface Area (BSA)	123

RESPIRATORY 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 *

Pulmonary edema	123
C.O.P.D.	123
Pulmonary emboli	123
Near drowning	123
Asthma	123
Nebulizer	123
Pneumonia	123
ABG interpretation	123

AIRWAY MANAGEMENT, CARE & MAINTENANCE 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 *

Oral / NT / ET airway	123
Tracheostomy	123
Obtaining ABG blood sample/arterial line	123
Pulse Oximetry	123
Capnography	123

VENTILATOR MANAGEMENT:

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 *

BiPAP (Bi-level Positive Airway Pressure)	123
Oscillation / high-frequency ventilation	123
Nitric	123
Interpretation of weaning parameters	123

VASCULAR ACCESS 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 *

Assist with intraosseous needle insertion	123
Assisting with a cut-down	123
Assist with central line insertion	123
Assist with arterial line insertion	123

ASSIST WITH INSERTION & or 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 *

Manage Care of CVC (Central Venous Catheter)	123
Manage Care of Arterial line	123

CARDIOVASCULAR 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 *

Acute MI	123
Unstable angina	123
Aneurysm (thoracic or abdominal)	123
CHF	123
Cardioversion	123
Defibrillation	123
Assist with insertion of a temporary pacemaker	123
Application of an external pacemaker	123
Cardiogenic shock	123

NEUROLOGICAL 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 *

Neuro assessment / monitoring	123
Use of Glasgow Coma Scale	123
Traumatic Brain Injury (TBI)	123
Acute T.I.A. / C.V.A.	123
Acute spinal injury	123
Migraine headache	123
Seizure precautions / status epilepticus	123
Assist with lumbar puncture	123
Transport of a patient with spinal cord injuries/cervical spine precautions	123
Observing for increased intracranial pressure	123

GASTROINTESTINAL EXPERIENCE - CARE OF PATIENT WITH:

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 *

GI and GU Bleed	123
Abdominal pain	123
NGT insertion	123
G-tube	123
J-tube	123
Bowel obstruction	123
Acute pancreatitis	123
Testicular torsion	123

OBSTETRICS/GYNECOLOGY 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 *

Assist with pelvic exams / obtaining cultures	123
Spontaneous abortion / hemorrhage	123
Ectopic pregnancy	123
Emergency delivery	123
Placenta previa	123
Preeclampsia / eclampsia	123
Doppler FHT (Fetal Heart Tones)	123

PEDIATRICS 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 *

Pediatric arrest / resuscitation	123
Use of Broslow resuscitation system	123
Overdose / poison ingestion	123
Child abuse	123
Sepsis management	123
Sickle cell anemia	123
Peds IV periph starts	123
Pediatric assessment/VS	123

RENAL 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 *

Acute renal failure	123
Chronic renal failure	123
Peritoneal dialysis	123
Fluid management / electrolyte replacement	123
Renal calculi	123
Foley cath / straight cath / clean cath urine	123

ORTHOPEDICS 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 *

Set up for cast application	123
Set up for OCL splinting	123
Assist with closed fracture / dislocation reductions	123
Instruction of application of orthopedic appliances	123
Assess extremity vascular circulation	123

PSYCHIATRIC 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 *

Drug/ETOH withdrawal	123
Care of overdose patient / gastric lavage	123
Care of a suicidal patient	123
Crisis intervention / management & assaultive behavior	123
Sexual assault	123
Rape kit	123
Reporting procedures for acts of violence	123

ENVIRONMENT 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 *

Hypothermia	123
Heat stroke / exhaustion	123
Human / animal bite	123
Snake bite	123
Anaphylaxis	123

EENT DISORDERS 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 *

Set up for fluorescein / woods lamp	123
Use of Morgan Lens / eye irrigation	123
Ear irrigations / FB removal	123
Assist with nasal packing	123
Visual acuity	123
Epiglottitis	123
Nose bleed / packing	123
Removal of nasal FB	123

EMERGENCY MEDICATIONS 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 *

Emergency ACLS medication prepare & administer	123
Tridil / nitroglycerin	123
Sodium bicarb	123
Heparin	123
Dilantin / cerebrex	123
Narcan	123
Decadron	123
Mannitol	123
Solumedrol	123
Phenobarbital	123
Fibrinolytics / IIb IIIa inhibitor	123
Nipride / cardene	123
Inotropics (i.e. digoxin, dopamine, epinephrine)	123
Rapid sequence intubation protocol & meds	123
Diprivan	123
Cardizem	123
Vasopressin	123
Romazicon	123
Levophed	123
Insulin / insulin GTT	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. *