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My responses in this checklist represent a true reflection of my experience and comfort level.

Please self-rate your comfort level in performing tasks in connection with the below checklist. Rate your level of comfort for each line item by following the below ranking system. Simply fill in the appropriate option immediately following the rating number.

 
   
 
 
   
Signature                :
    
   
Date                :
    
          Phone                :
  
My Recruiting Professional at Health Source Group is:    

 
Level of Comfort/Experience

N/A=Non-applicable

1=Inexperienced in this area

2=Limited comfort/experience in this area

3=Comfortable/experienced in this area

4=Very comfortable/highly experienced in this area

 

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Cardiovascular

Assessment of heart Sounds

N/A  

1

2

3

4

Interpret basic arrythmias

N/A  

1

2

3

4

Can Perform Emergency Defibrillation

N/A  

1

2

3

4

Controlled cardioversion

N/A  

1

2

3

4

CVP monitoring via water manometer

N/A  

1

2

3

4

Radial art line (set-up and monitor)

N/A  

1

2

3

4

Interpretation of Cardiac enzymes and ISO enzymes

N/A  

1

2

3

4

Interpretation of coags (PTT, PT, ACT)

N/A  

1

2

3

4

Thrombolytic studies

N/A  

1

2

3

4

Electrophysiological studies (ablations)

N/A  

1

2

3

4

Cardiac rehab-patient teaching

N/A  

1

2

3

4

 

Invasive Procedures

Valvuloplasty

N/A  

1

2

3

4

Intracoronary Stent placement

N/A  

1

2

3

4

Rotoblation

N/A  

1

2

3

4

Heart biopsies

N/A  

1

2

3

4

Pericardial taps

N/A  

1

2

3

4

Atherectomies

N/A  

1

2

3

4

Temporary pacemakers

N/A  

1

2

3

4

Permanent pacemakers

N/A  

1

2

3

4

Intracoronary stents

N/A  

1

2

3

4

IABP(Intra Aortic Balloon Pump)

N/A  

1

2

3

4

Pediatric cardiac cathetertization

N/A  

1

2

3

4

 

Administering first line emergency drugs

Atropine

N/A  

1

2

3

4

Epinephrine

N/A  

1

2

3

4

Lidocaine

N/A  

1

2

3

4

Bretylium

N/A  

1

2

3

4

 

Administering drips

Heparin

N/A  

1

2

3

4

Nitroglycerine

N/A  

1

2

3

4

Nipride (Nitroprusside)

N/A  

1

2

3

4

Verapamil (Calan,Isoptin,Verelan)

N/A  

1

2

3

4

Dopamine (Inotropin)

N/A  

1

2

3

4

Caridazem (Dilitiazem Hydrochloride)

N/A  

1

2

3

4

 

Neurological

Assessment of LOC

N/A  

1

2

3

4

Seizure precautions

N/A  

1

2

3

4

Treating hypo/hyperthermia

N/A  

1

2

3

4

Treating emphysema

N/A  

1

2

3

4

Status asthmaticus

N/A  

1

2

3

4

Treating ARDS

N/A  

1

2

3

4

Post thoracotomy

N/A  

1

2

3

4

Sedation monitoring

N/A  

1

2

3

4

Alzheimers

N/A  

1

2

3

4

Overdose

N/A  

1

2

3

4

in restraints

N/A  

1

2

3

4

 

Gastrointestinal

Bowel sound assessment

N/A  

1

2

3

4

Insertion of nasogastric tube

N/A  

1

2

3

4

 

Renal

Insertion of straight and Foley catheters

N/A  

1

2

3

4

Three way Foley/bladder irrigation management

N/A  

1

2

3

4

 

Infusion Therapy

IV Insertion

N/A  

1

2

3

4

Phlebotomy

N/A  

1

2

3

4

Administration of blood and blood products

N/A  

1

2

3

4

Central line (Hickman, Broviac, Groshong, PICC)

N/A  

1

2

3

4

Use of infusion pumps

N/A  

1

2

3

4

Mix/administer IV meds

N/A  

1

2

3

4

PCA Pumps

N/A  

1

2

3

4

Titration of drips

N/A  

1

2

3

4

 

Pulmonary

Assessment of breath sounds

N/A  

1

2

3

4

Assessment of breathing patterns

N/A  

1

2

3

4

Pulse oximetry

N/A  

1

2

3

4

Oropharyngeal suctioning

N/A  

1

2

3

4

Tracheostomy suctioning

N/A  

1

2

3

4

Sputum specimen collection via suctioning

N/A  

1

2

3

4

Establishing an airway

N/A  

1

2

3

4

Interpretation of ABG’s

N/A  

1

2

3

4

Ambuing techniques

N/A  

1

2

3

4

Assist with intubation & extubation

N/A  

1

2

3

4

with pulmonary edema

N/A  

1

2

3

4

with pulmonary emboli

N/A  

1

2

3

4

with chest tubes

N/A  

1

2

3

4

 

 
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