Endoscopy 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

PROCEDURES 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 EGD’s	123
Assist with endoscopic ultrasound	123
Assist with active GI bleed	123
Cautery devices	123
Assist with manometry studies	123
Assist with variceal banding	123
Assist with esophageal dilatations	123
Assist with esophageal ballooning	123
Assist with scelrotherapy	123
Assist with TEE	123
Assist with bronchoscopy	123
Assist with colonoscopy	123
Assist with polypectomy	123
Assist with ERCP’s	123
Assist with PEG placements	123
Assist with liver BX	123
Assist with collection of hot & cold BX’s	123
Specimen collection & labeling	123
Set up of scopes & video equipment	123
Apply external abdominal pressure to assist with scope movement	123
Scope cleaning	123
Assist with mobile cases, ICU, ER, etc.	123
Radiation safety	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Takes call for emergency cases	123
National Patient Safety Goals	123
Awareness of HCAHPS	123
Accurate patient identification	123
Effective communication	123
Interpretation & communication of lab values	123
Medication administration	123
Labeling (medications & specimens)	123
Anticoagulation therapy	123
Monitoring conscious sedation	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123
Use of rapid response teams	123

ADMINISTER CONSCIOUS SEDATION:

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 *

Fentanyl	123
Propofol	123
Demerol	123
Presedex	123
Versed	123
Reversal agents	123

PRE PROCEDURE:

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 *

Pre procedure phone calls	123
Electronic documentation	123
Patient assessment	123
Colon prep or re-prep	123
Pre procedure checklist / consent	123
IV start, med admin	123
Time Out Protocol	123

POST PROCEDURE:

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 *

Assess for air movement post colonoscopy	123
Assess for pain	123
Assess for bowel sounds	123
Assess for gag reflex post EGD	123
Assess for gag reflex post bronchoscopy	123
Recover from MAC	123
Recover from (moderate) conscious sedation	123
Discharge outpatients to home	123
Post procedure phone calls	123

AGE-SPECIFIC COMPETENCIES 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. *