Cath Lab / Interventional Radiology Nursing Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information HiddenOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security Number Email(Required) HiddenDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWORK SETTINGProcedural Cath Lab(Required) 1 2 3 4 lnterventional Cath Lab(Required) 1 2 3 4 EP Lab(Required) 1 2 3 4 Interventional Radiology(Required) 1 2 3 4 Pre/Post Procedural Setting(Required) 1 2 3 4 Charge Experience(Required) 1 2 3 4 Other Setting (List)(Required) 1 2 3 4 EQUIPMENTAutomatic Implantable Cardiac Defibrillator(Required) 1 2 3 4 Cardioversion(Required) 1 2 3 4 Intra Aortic Balloon Pump (IABP)(Required) 1 2 3 4 SV02 Recording(Required) 1 2 3 4 Ventilator Management(Required) 1 2 3 4 CARDIAC CATH LAB PROCEDURESAICD Placement(Required) 1 2 3 4 Aortography(Required) 1 2 3 4 Cardiac Biopsy(Required) 1 2 3 4 Cardiac Implant Closure Device(Required) 1 2 3 4 Cardiac Stent Placement(Required) 1 2 3 4 Diagnostic Cardiac Catheterization Adult(Required) 1 2 3 4 Diagnostic Cardiac Catheterization-Pediatric/Neonatal(Required) 1 2 3 4 Directional Coronary Atherectomy(Required) 1 2 3 4 IABP Placement/Removal(Required) 1 2 3 4 Internal Mammary Angiography(Required) 1 2 3 4 Laser Assisted Procedures(Required) 1 2 3 4 Percutaneous Transluminal Coronary Angioplasty(Required) 1 2 3 4 Pericardiocentesis(Required) 1 2 3 4 Permanent Pacemaker Placement(Required) 1 2 3 4 Pulmonary Angiography(Required) 1 2 3 4 Rotational Coronary Atherectomy(Required) 1 2 3 4 Saphenous Vein Graft Angiography(Required) 1 2 3 4 Transluminal Extraction Catheter(Required) 1 2 3 4 Valvuloplasty(Required) 1 2 3 4 Ventricular Assist Device Insertion(Required) 1 2 3 4 ELECTROPHYSIOLOGY PROCEDURESElectrophysiology Evaluation(Required) 1 2 3 4 Baseline Measurements(Required) 1 2 3 4 Cardiac Ablation(Required) 1 2 3 4 Cardiac Mapping(Required) 1 2 3 4 Cardioversion(Required) 1 2 3 4 Conduction Study(Required) 1 2 3 4 Internal Cardioverter Defibrillator Implant(Required) 1 2 3 4 Tilt Table Study(Required) 1 2 3 4 IR-GASTROINTESTINAL STUDIESAngioplasty(Required) 1 2 3 4 Chemoembolization(Required) 1 2 3 4 Cholecystostomy(Required) 1 2 3 4 Embolization(Required) 1 2 3 4 ERCP(Required) 1 2 3 4 Esophageal Stent Placement(Required) 1 2 3 4 Gastrojejunostomy(Required) 1 2 3 4 Gastrostomy Tube Placement(Required) 1 2 3 4 Liver Ablation(Required) 1 2 3 4 Pericentesis(Required) 1 2 3 4 Percutaneous Hepatic Angiography(Required) 1 2 3 4 TIPS(Required) 1 2 3 4 IR-GENITOURINARY STUDIESAdrenal Angiography(Required) 1 2 3 4 Angiography of Female GU System(Required) 1 2 3 4 Angiography of Male GU System(Required) 1 2 3 4 Cystostomy(Required) 1 2 3 4 Embolization(Required) 1 2 3 4 Nephrostomy(Required) 1 2 3 4 Percutaneous Stone Extraction(Required) 1 2 3 4 Renal Angiography(Required) 1 2 3 4 Renal Artery Angioplasty(Required) 1 2 3 4 Renal Artery Stent Placement(Required) 1 2 3 4 Ureteral Stent(Required) 1 2 3 4 IR-NEUROLOGIC STUDIESCerebral Angiography(Required) 1 2 3 4 Carotid Angiography(Required) 1 2 3 4 Neurologic Angioplasty(Required) 1 2 3 4 Neurologic Thrombolysis(Required) 1 2 3 4 Vertebroplasty(Required) 1 2 3 4 IR-PERIPHERAL VASCULAR STUDIESIR-PERIPHERAL VASCULAR STUDIES(Required) 1 2 3 4 Angioplasty(Required) 1 2 3 4 Central Venous Access/Port Placement(Required) 1 2 3 4 Dialysis Graft Creation/Revision(Required) 1 2 3 4 Dialysis Graft lnterventional(Required) 1 2 3 4 Peripheral Vascular Embolization(Required) 1 2 3 4 Stent Graft Placement(Required) 1 2 3 4 SVC/IVC Venograph(Required) 1 2 3 4 Thoracic Aortography(Required) 1 2 3 4 Upper and Lower Extremity Angiography(Required) 1 2 3 4 IR-PULMONARY PROCEDURESChest Tube Placement(Required) 1 2 3 4 Pulmonary Embolization(Required) 1 2 3 4 Pulmonary Angiography(Required) 1 2 3 4 Thoracentesis(Required) 1 2 3 4 PROFESSIONAL KNOWLEDGE AND SKILLSConscious/Procedural Sedation(Required) 1 2 3 4 Assist w/Central Line/Venous Line Insertion(Required) 1 2 3 4 Venous Sampling(Required) 1 2 3 4 Topical Hemostasis (D-Stat, Chito-Seal, Syvek Patch, etc.)(Required) 1 2 3 4 Vascular Closure Systems (Perclose, StarClose, etc.)(Required) 1 2 3 4 External Compression Devices (C-Clamp, Sandbags,etc.)(Required) 1 2 3 4 Physiologic Monitoring/Recording(Required) 1 2 3 4 Sheath Removal and Monitoring(Required) 1 2 3 4 National Patient Safety Goals/Core Measures(Required) 1 2 3 4 Universal Protocol Procedures(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 Infection Prevention(Required) 1 2 3 4 Age Specific/Population-Based Care(Required) 1 2 3 4 Fall Risk Assessment/Prevention(Required) 1 2 3 4 EMRCerner(Required) 1 2 3 4 Eclipsys(Required) 1 2 3 4 Epic(Required) 1 2 3 4 GE(Required) 1 2 3 4 McKesson(Required) 1 2 3 4 Meditech(Required) 1 2 3 4 Other Computerized System(Required) 1 2 3 4 Computerized Physician Order Entry(Required) 1 2 3 4 Medication Administration using Bar Coding Technology(Required) 1 2 3 4 EMR Conversion(Required) Yes No CERTIFICATIONSBLS(Required) Yes No BLS Expiry Date MM slash DD slash YYYY ACLS(Required) Yes No ACLS Expiry Date MM slash DD slash YYYY PALS(Required) Yes No PALS Expiry Date MM slash DD slash YYYY CCRN(Required) Yes No CCRN Expiry Date MM slash DD slash YYYY Telemetry Certificate(Required) Yes No Telemetry Certificate Expiry Date MM slash DD slash YYYY Arrhythmia Course(Required) Yes No Arrhythmia Course Expiry Date MM slash DD slash YYYY Other: Specify Other: Specify - Expiry Date MM slash DD slash YYYY Age Specific CompetenciesInfant (Birth - 1 year)(Required) 1 2 3 4 Preschooler (ages 2-5 years)(Required) 1 2 3 4 Childhood (ages 6-12 years)(Required) 1 2 3 4 Adolescents (ages 13-21 years)(Required) 1 2 3 4 Young Adults (ages 22-39 years)(Required) 1 2 3 4 Adults (ages 40-64 years)(Required) 1 2 3 4 Older Adults (ages 65-79 years)(Required) 1 2 3 4 Elderly (ages 80+ years)(Required) 1 2 3 4 AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. 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