TELEMETRY/STEPDOWN 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 independentlyCardiovascular Care of Patient withAcute MI(Required) 1 2 3 4 CHF(Required) 1 2 3 4 Angina Hypertension(Required) 1 2 3 4 Cardiomyopathy Cardiopulmonary Arrest(Required) 1 2 3 4 Abdominal Aortic Aneurysm(Required) 1 2 3 4 Carotid Endarterectomy(Required) 1 2 3 4 Femoral Popliteal Bypass(Required) 1 2 3 4 Pre & Post Cardiac Surgery(Required) 1 2 3 4 Pre & Post Cardiac Cath(Required) 1 2 3 4 Pre & Post PTCA(Required) 1 2 3 4 Permanent Pacemaker Temporary PacemakerExternal Pacemaker(Required) 1 2 3 4 Cardiac Lab Interpretation(Required) 1 2 3 4 Cardiac Patient/Family Teaching(Required) 1 2 3 4 RespiratioryRespiratory Assessment(Required) 1 2 3 4 Assess Lung Sounds(Required) 1 2 3 4 Chest Percussion(Required) 1 2 3 4 Establish/Protect Airway(Required) 1 2 3 4 Chest tubes/Pleurevac(Required) 1 2 3 4 Oxygen Therapy(Required) 1 2 3 4 Drawing ABGs(Required) 1 2 3 4 Interpretation of ABGs(Required) 1 2 3 4 Incentive Spirometry(Required) 1 2 3 4 Suctioning: oral nasotracheal endotracheal tube tracheostomy tube(Required) 1 2 3 4 Oxygen Equipment Set Up and Maintenance: nasal canula non-rebreather mask venti-mask ET(Required) 1 2 3 4 Inturbation/extubationambu bag pulse oximetry(Required) 1 2 3 4 Care of patient with: COPD tracheostomy pulmonary edema ARDS ventilator (A/C, IMV, PEEP) pre/post-op thoracis surgery pneumonia chest tubes asthma emphysema(Required) 1 2 3 4 NeurologyNeurological Assessment(Required) 1 2 3 4 Seizure Precautions(Required) 1 2 3 4 Assessment and Management of Seizure Activity(Required) 1 2 3 4 Assisting with Lumbar Puncture(Required) 1 2 3 4 Signs/Symptoms of Increasing ICP(Required) 1 2 3 4 Glascow Coma Scale(Required) 1 2 3 4 Crutchfield Tongs(Required) 1 2 3 4 Circo-electric Bed Halo Traction(Required) 1 2 3 4 Stryker Frame(Required) 1 2 3 4 Care of patient with: seizures CNS infection overdose DTs spinal cord injury acute head injury CVA/TIA neuromuscular disease pre/post neuro surgery(Required) 1 2 3 4 GastrointestinalG.I. Assessment(Required) 1 2 3 4 Bowel Sounds(Required) 1 2 3 4 Inserting N-G Tubes(Required) 1 2 3 4 Colostomy Care(Required) 1 2 3 4 Measurement of I & O(Required) 1 2 3 4 Administration of Tube Feedings(Required) 1 2 3 4 Care of patients with: GI bleed NG tube G-tube J-tube abdominal wounds/surgeries inflammatory bowel disease bowel obstruction(Required) 1 2 3 4 Renal/GenitourinaryRenal/Genitourinary(Required) 1 2 3 4 Care of Patient with: Bladder Irrigation Suprapubic Tube Nephrostomy Tube Renal Transplant Nephrectomy Renal Transplant BPH Pre/post Turp(Required) 1 2 3 4 OrthopedicTotal Knee Replacement(Required) 1 2 3 4 Bucks Extension(Required) 1 2 3 4 Cast Care(Required) 1 2 3 4 Crutch Walking(Required) 1 2 3 4 K-Wires(Required) 1 2 3 4 Spica Casts(Required) 1 2 3 4 Balanced Suspension Traction(Required) 1 2 3 4 Circulation Checks(Required) 1 2 3 4 Care of Patient with: Amputation Rheumatic/Arthritic Disease Multiple Trauma Paraplegia External Fixation Post Arthroplasty(Required) 1 2 3 4 GeneralBlood Glucose Monitoring(Required) 1 2 3 4 Dressing Changes(Required) 1 2 3 4 Universal Precautions(Required) 1 2 3 4 Isolation(Required) 1 2 3 4 Discharge Planning(Required) 1 2 3 4 Care of Patient with: Diabetes Pressure Sores Sickle Cell Anemia Cancer Alzheimer's Disease HIV/AIDS(Required) 1 2 3 4 MedicationsUnit Dose(Required) 1 2 3 4 Dosage Calculation(Required) 1 2 3 4 Pouring from Stock Medication(Required) 1 2 3 4 Administration of Code Cart Emergency Drugs(Required) 1 2 3 4 Aminophylline(Required) 1 2 3 4 Ativan(Required) 1 2 3 4 Atropine(Required) 1 2 3 4 Chemotherapy Agents(Required) 1 2 3 4 Corticosteroids(Required) 1 2 3 4 Decadron(Required) 1 2 3 4 Digoxin(Required) 1 2 3 4 Dilantin(Required) 1 2 3 4 Dopamine(Required) 1 2 3 4 Heparin Inhalers(Required) 1 2 3 4 Lidocaine(Required) 1 2 3 4 Lopressor(Required) 1 2 3 4 Magenesium Sulfate(Required) 1 2 3 4 Nipride Nitroglycerin(Required) 1 2 3 4 Phenobarbital(Required) 1 2 3 4 Thrombolytic Agents(Required) 1 2 3 4 Valium(Required) 1 2 3 4 Verapamil(Required) 1 2 3 4 IV TherapyInserting IVs Mixing IV solutions(Required) 1 2 3 4 Heparin Locks(Required) 1 2 3 4 TPN/Hyperalimentation(Required) 1 2 3 4 IV push IV drip Infusion pumps Syringe pumps(Required) 1 2 3 4 Continuous Subcutaneous Infusion Pumps(Required) 1 2 3 4 PCA Pumps(Required) 1 2 3 4 Ultrasonic Doppler(Required) 1 2 3 4 CVP Lines/Measurement of CVP(Required) 1 2 3 4 Central Line Dressing Change(Required) 1 2 3 4 Blood/Blood products administration ordering/obtaining from blood bank identification/intercession for adverse reaction(Required) 1 2 3 4 Multi-lumen central venous catheters Implanted CVC (port-a-cath)(Required) 1 2 3 4 Assessment of IV insertion site(Required) 1 2 3 4 Assist with Insertion of Central Line(Required) 1 2 3 4 X-ray/Assessment After Insertion(Required) 1 2 3 4 Care of Patient with Central Line(Required) 1 2 3 4 Charge Nurse Experience?(Required) 1 2 3 4 CPR Certified?(Required) 1 2 3 4 BCLS Certified?(Required) 1 2 3 4 ACLS Certified?(Required) 1 2 3 4 Knowledge of Normal Values?(Required) 1 2 3 4 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. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
