Emergency Trauma Competency Self Assessment
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- Ilene Hart
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1 Emergency Trauma Competency Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date General Skills Advanced directives HIPAA Patient/family teaching Restrictive devices (restraints) Lift/transfer devices Specialty beds End of life care/palliative care Post mortem care Automated Medication Dispensing System, Pyxis, Omnicell, or other Bar coding for medication administration Triage Organ donor protocols Consent for treatment of a minor Procedure for a patient signing out AMA Knowledge of cobra criteria/transfer patients Disaster protocols National Patient Safety Goals Accurate patient identification Effective communication Interpretation & communication of lab values Medication administration Labeling Anticoagulation therapy Medication reconciliation Monitoring conscious sedation Pain assessment & management Infection control Universal precautions Isolation Minimize risk for falls Awareness of HCAHPS MedStaff Healthcare Solutions Rev. 09/12 F0365 ER Trauma 1 of 7
2 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) General Skills - cont. Prevention of pressure ulcers Wound care Suture tray set up Cardiac Monitoring & Emergency Care Obtains 12 lead EKG Interpretation of rhythm strips Treatment of dysrythmias Use of rapid response teams Cardiac arrest/cpr Code cart set up and shift checks O2 therapy & delivery Pulse oximetry Use of doppler IV Therapy Starting & maintaining peripheral IVs Blood draw: venous Central line care Blood draw: central line Care & management of ports Care & management of PICC/Groshong/Hickman Administration of blood/blood products Diabetes mellitus Blood Glucose Monitoring (BGM) Insulin administration Trauma Trauma score Critical transports Air transport (helicopter or jet) Other transport experience Level 1 trauma Level 2 trauma Level 1 infuser Open chest massage Peritoneal lavage Hypovolemic shock H+H/stat lab test machine Post drowning Auto transfuser/warmer MedStaff Healthcare Solutions Rev. 09/12 F0365 ER Trauma 2 of 7
3 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Burns First degree Second degree Third degree Electrocution Hazardous material exposure/contamination Calculation of total Body Surface Area (BSA) Respiratory Pulmonary edema C.O.P.D Pulmonary emboli Near drowning Asthma Nebulizer Pneumonia ABG interpretation Vascular Access Assist with intraosseous needle insertion Assisting with a cut-down Assist with central line insertion Assist with arterial line insertion Cardiovascular Acute MI Unstable angina Aneurysm (thoracic or abdominal) CHF Cardioversion Defibrillation Assist with insertion of a temporary pacemaker Application of an external pacemaker Cardiogenic shock Neurological Neuro assessment/monitoring Use of Glasgow Coma Scale Traumatic Brain Injury (TBI) MedStaff Healthcare Solutions Rev. 09/12 F0365 ER Trauma 3 of 7
4 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Neurological - cont. Acute T.I.A./C.V.A Acute spinal injury Migraine headache Seizure precautions/status epilepticus Assist with lumbar puncture Transport of a patient with spinal cord injuries/cervical spine precautions Observing for increased intracranial pressure Gastrointestinal Care of Patient with: GI bleed Abdominal pain NGT insertion G-tube J-tube Bowel obstruction Acute pancreatitis Testicular torsion Obstetrics/Gynecology Assist with pelvic exams/obtaining cultures Spontaneous abortion/hemorrhage Ectopic pregnancy Emergency delivery Placenta previa Preeclampsia/eclampsia Doppler FHT (Fetal Heart Tones) Pediatrics Pediatric arrest/resuscitation Use of Broslow resuscitation system Overdose/poison ingestion Child abuse Sepsis management Sickle cell anemia Peds IV periph starts Pediatric assessment/vs MedStaff Healthcare Solutions Rev. 09/12 F0365 ER Trauma 4 of 7
5 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Renal Acute renal failure Chronic renal failure Peritoneal dialysis Fluid management/electrolyte replacement Renal calculi Foley cath/straight cath/clean cath urine Orthopedics Set up for cast application Set up for OCL splinting Assist with closed fracture/dislocation reductions Instruction of application of orthopedic appliances Assess extremity vascular circulation Psychiatric Drug/ETOH withdrawal Care of overdose patient/gastric lavage Care of a suicidal patient Crisis intervention/management & assaultive behavior Sexual assault Rape kit Reporting procedures for acts of violence Environment Hypothermia Heat stroke/exhaustion Human/animal bite Snake bite Anaphylaxis EENT Disorders Set up for fluorescein/woods lamp Use of Morgan Lens/eye irrigation Ear irrigations/fb removal Assist with nasal packing Visual acuity Epiglottitis Nose bleed/packing Removal of nasal FB MedStaff Healthcare Solutions Rev. 09/12 F0365 ER Trauma 5 of 7
6 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Emergency Medications Emergency ACLS medication prepare & administer Tridil/nitroglycerin Sodium bicarb Heparin Dilantin/cerebrex Narcan Decadron Mannitol Solumedrol Phenobarbital Fibrinolytics/IIb IIIa inhibitor Nipride/cardene Inotropics (i.e. digoxin, dopamine, epinephrine) Rapid sequence intubation protocol & meds Diprivan Cardizem Vasopressin Romazicon Levophed Insulin/insulin GTT Age Specific Competencies Newborn/neonate (birth-30 days) Infant (31 days-1 year) Toddler (ages 2-3 years) Preschool (ages 4-5 years) School age (ages 6-12 years) Adolescent (ages years) Young adult (ages years) Adult (ages years) Older adult (ages years) Elderly (ages 80+ years) MedStaff Healthcare Solutions Rev. 09/12 F0365 ER Trauma 6 of 7
7 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Please list any Additional Skills: Additional training: Additional equipment: Fax to: The information on this and all preceding pages is true and correct. Signature Date 2012 MedStaff Healthcare Solutions Rev. 09/12 F0365 ER Trauma 7 of 7
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