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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= comfortable/highly experienced in this area

Area

Not applicable

Inexperienced

Limited

Experienced

Highly Experienced

EXPERIENCE

Acute/Inpatient Dialysis

N/A  

1

2

3

4

Chronic/Outpatient Dialysis

N/A  

1

2

3

4

Dialysis Home Care

N/A  

1

2

3

4

Pediatric Dialysis

N/A  

1

2

3

4

Teaching the Dialysis Patient and Family

N/A  

1

2

3

4

Charge Nurse Experience

N/A  

1

2

3

4

 

SET UP/INITIATE DIALYSIS TREATMENT

Bicarbonate Dialysate

N/A  

1

2

3

4

Conductivity Testing

N/A  

1

2

3

4

Priming Dialyzer

N/A  

1

2

3

4

Machine and Alarm Setting Checks

N/A  

1

2

3

4

Prep Vascular Access

N/A  

1

2

3

4

Fistula/Vein Graft

N/A  

1

2

3

4

Dialysis

N/A  

1

2

3

4

Blood Specimen Collection

N/A  

1

2

3

4

Anticoagulation

N/A  

1

2

3

4

 

ASSESSMENT AND CARE OF PATIENT DURING DIALYSIS

Systems Assessment of Patient

N/A  

1

2

3

4

Volume Status

N/A  

1

2

3

4

Vascular Access Function

N/A  

1

2

3

4

Arterial and Venous Pressures

N/A  

1

2

3

4

Blood Flow Rate

N/A  

1

2

3

4

Subjective Response to Treatment

N/A  

1

2

3

4

Assess and Management of Anticoagulation

N/A  

1

2

3

4

Conductivity

N/A  

1

2

3

4

Ultrafiltration Calculation

N/A  

1

2

3

4

Administration of Blood and Blood Products

N/A  

1

2

3

4

Administration of Mannitol

N/A  

1

2

3

4

Sequential Ultrafiltration/PUF

N/A  

1

2

3

4

Documentation of Dialysis Treatment

N/A  

1

2

3

4

 

MANAGEMENT OF THE PATIENT WITH

Air Embolus

N/A  

1

2

3

4

Anemia

N/A  

1

2

3

4

Blood Leak

N/A  

1

2

3

4

Cardiopulmonary Arrest

N/A  

1

2

3

4

Chest Pain

N/A  

1

2

3

4

Disequilibrium Syndrome

N/A  

1

2

3

4

Fluid Overload

N/A  

1

2

3

4

Hemolysis

N/A  

1

2

3

4

Hyperkalcemia

N/A  

1

2

3

4

Hypertension

N/A  

1

2

3

4

Hypotension

N/A  

1

2

3

4

Muscle Cramps

N/A  

1

2

3

4

Neuropathy

N/A  

1

2

3

4

Pericarditis

N/A  

1

2

3

4

Pyrogenic Reaction

N/A  

1

2

3

4

 

PROCEDURES FOR TROUBLESHOOTING MACHINE ALARMS

Air/Foam Detector Alarm

N/A  

1

2

3

4

Air Leak

N/A  

1

2

3

4

Arterial Pressure Alarm

N/A  

1

2

3

4

Blood Leak Alarm

N/A  

1

2

3

4

High Temperature Alarm

N/A  

1

2

3

4

Power Failure Alarm

N/A  

1

2

3

4

Ultrafiltration Alarm

N/A  

1

2

3

4

Venous Pressure Alarm

N/A  

1

2

3

4

 

DISCONTINUE DIALYSIS

Dialysis Catheter

N/A  

1

2

3

4

Fistula/Vein Graft

N/A  

1

2

3

4

Return of Blood

N/A  

1

2

3

4

Post-Treatment Access Care

N/A  

1

2

3

4

Equipment Clean-Up

N/A  

1

2

3

4

 

RENAL/GU

Assessment of Renal/GU System

N/A  

1

2

3

4

Foley Catheter Insertion

N/A  

1

2

3

4

Acute Renal Failure

N/A  

1

2

3

4

AV Fistula/AV Graft

N/A  

1

2

3

4

Chronic Renal Failure

N/A  

1

2

3

4

Ileal Conduit

N/A  

1

2

3

4

Nephrectomy

N/A  

1

2

3

4

Nephrostomy Tube

N/A  

1

2

3

4

Peritoneal Dialysis

N/A  

1

2

3

4

Supra-Pubic Catheter

N/A  

1

2

3

4

Tunneled/Non-Tunneled Catheter

N/A  

1

2

3

4

TURP

N/A  

1

2

3

4