MEDICAL / SURGICAL TELEMETRY SKILLS CHECKLIST NAME: PHONE: EMAIL: LEVEL OF PROFICIENCY Theory No Experience 1 Minimal Experience (0-12 Months) 2 Experienced/Competent (Greater than 12 Months) 3 Able to Teach/Supervise 4 SKILLS - MEDI CATION ADMINISTRATION 1 2 3 4 IM Injections Intradermal Injections Subcutaneous Injections IV Push Medications IV Additives and Piggybacks Epidural Pumps PCA Pumps Infusion Pumps Respiratory 1 2 3 4 Assessment of Breath Sounds Establishing an Airway Ambuing Techniques Oxygen Therapy Nasal Cannula Prongs Ventimask Rebreather/Non Rebreather Mask Pulse Oxymeter Sputum Collections 1 2 3 4 Orally Sputum Trap Interpretation of ABG's Use of IPPB Incentive Spirometer Oral Suctioning Nasotracheal Suctioning Tracheal Suctioning Care of the Tracheostomy COPD ARDS Thoracic Surgery Asthma
Inhalation Injuries Pneumonia Pneumothorax Tuberculosis Pulmonary Edema Pulmonary Embolism Inhalation Therapies Cardiac 1 2 3 4 Assessment of Heart Sounds Cardiac Arrest/CPR Administration of Emergency Medications Use of Defibrillator Use of Cardioversion Neurology 1 2 3 4 Neuro Assessment Glascow Coma Scale Seizure Precautions Seizure Activity Assist with Lumbar Puncture Halo Traction CVA/TIA Overdose Head Injury/Trauma Spinal Cord Injury Paraplegia Quadraplegia Neuro Sugery Cranial Hemorrhage AV-Shunt Placement Multiple Sclerosis Gastrointestinal 1 2 3 4 Assessment of Bowels Sounds NG Tube Insertion Gastrostomy Tube Insertion Jejunostomy Tube Care Enterostomal Care Jackson-Pratt Drain Penrose Drain Insertion/Verfication of Feeding Tube Continuous Feeding Pump Gravity Drainage
Appendicitis GI Bleed Pancreatitis Bowel Obstruction Paralytic Ileus Liver Failure Hepatitis Laparoscopic Abd Procedures Open Abd Procedures Renal 1 2 3 4 Foley Catheter Insertion Male Foley Catheter Insertion Female GU Irrigation Suprepubic Catheters External Catheters Nephrostomy Tubes Electrolyte Imbalance/Replacement Chronic/Acute Renal Failure Renal Calculi Renal Trauma Nephrectomy TURP Radical Prostectomy Hemodialysis Peritoneal Dialysis Vascular 1 2 3 4 Care of the Gortex Graft Care of the Ateriovenous Shunt TPN/Hyperalimentation Deep Vein Thrombosis Cellulitis Quinton/Permacaths Groshong Catheters Hickman/Broviac Catheters Maintence of Heparin/Saline Lock Assist with Insertion of Central Line Venipuncture Administration of Blood/Blood Products Peripheral Pulses Fluid Overload Ultrasonic Doppler Sickle Cell Anemia
Transfusion Reaction Anaphylaxis Septic Shock Anasarea Orthopedic 1 2 3 4 Amputation Arthroscopic Surgery Total Joint Replacement Cast Care Orthopedic Trauma Urinary tract infection Vulvovaginitis Hydrocele Gonococcal infections Prostatitis Hypospadias Benign prostatic hypertrophy Skeletal Traction Bucks Traction Pin Site Care Laminectomy Passive ROM Exercises Gynecology 1 2 3 4 Mastectomy Hysterectomy Tubal Ligation Ectopic Pregnancy Abdominoplasty Reconstructive Breast Surgery Thyroidectomy Assist/Perform GYN Exam/Pap Removal of Cysts Other 1 2 3 4 Accuchecks Burn Patients Diabetic Teaching Isolation Techniques Chemotherapy Oncology Patient Teaching Nutritional Teaching Knowledge of Normal Lab Values Simple Dressing Changes
Complex Dressing Changes Skin Assessment Fall Assessment Soft Restraints Posey Restraints Informed Consent Delirium Tremors HIV Antibiotic Resistant Infection Telemetry 1 2 3 4 Obtaining 12 Lead EKG's Interpretation of EKG Arrhythmia Interpretation Monitor Set-Up Lead Placement Pacemakers A Line (set-up and D/C) Sheath Removal-Femoral Care of Patient with 1 2 3 4 Angina Aneurysm MI Hypertensive Crisis Open Heart Surgery (Pre & Post) CHF Cardiac Cath Fem/Pop Bypass Respiratory 1 2 3 4 Chest Tubes Obtaining Blood Sample for ABG Artetial Puncture Vascular 1 2 3 4 Care of the Gortex Graft Care of the AV Shunt Assist with Central Line Insertion MEDICATIONS 1 2 3 4 Amiodarone Atropine Bretylium Cardizem Digoxin Dopamine
Epinephrine Heparin Inderal Lidocaine Morphine Vasopressin Nipride Nitroglycerin Quinidine Sodium Bircarbonate Verapamil Certification(s) BLS ACLS NRP PALS OTHER OTHER Expiration Date(s) Licensure(s) Number(s) State(s) Expiration Date(s) AREAS OF EXPERTISE MONTHS YEARS Management Duties Charge Duties Please enter information you feel is important or necessary to give further explanation for information provided above: By signing my name in the space provided below, I attest that I have completed the above form accurately and truthfully and have in no way misrepresented my skills or abilities. Employee Signature: Date: Completed By: Date: Title: