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.
Typed Name (typing your name below serves as an electronic signature)* Date*
Phone*
My Recruiting
Professional at Health Source Group is:
Certifications:(Check all that apply)
BLS/BCLS/CPR:
ACLS:
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
Arrhythmia interpretation
N/A
1
2
3
4
Heart Sounds interpretation
N/A
1
2
3
4
Placement of patient on cardiac monitor
N/A
1
2
3
4
Basic 12 lead ECG interpretation
N/A
1
2
3
4
Defibrillation/cardioversion
N/A
1
2
3
4
Temporary external pacing
N/A
1
2
3
4
Temporary transvenous
N/A
1
2
3
4
Temporary epicardial wires
N/A
1
2
3
4
Permanent
N/A
1
2
3
4
Swan Ganz hemodynamic monitoring
N/A
1
2
3
4
Central venous catheter
N/A
1
2
3
4
Arterial line (A-line)
N/A
1
2
3
4
Use of Doppler
N/A
1
2
3
4
Post open heart patient
N/A
1
2
3
4
Heart transplant patient
N/A
1
2
3
4
Pre/post cardiac patient
N/A
1
2
3
4
24-48 hours post MI patient
N/A
1
2
3
4
CHF patient (congestive heart failure)
N/A
1
2
3
4
Carotid endarterectomy patient
N/A
1
2
3
4
Fem-pop bypass patient (femoral-popliteal)
N/A
1
2
3
4
Dobutamine
N/A
1
2
3
4
Dopamine
N/A
1
2
3
4
Epinephrine
N/A
1
2
3
4
Heparin
N/A
1
2
3
4
Lidocaine
N/A
1
2
3
4
Nitroglycerine (Nitro)
N/A
1
2
3
4
Pronestyl
N/A
1
2
3
4
Pulmonary
Assist with extubation
N/A
1
2
3
4
Assist with intubation
N/A
1
2
3
4
Chest physiotherapy
N/A
1
2
3
4
Assessment of breath sounds
N/A
1
2
3
4
Monitor pulse oximetry
N/A
1
2
3
4
Ventilator management
N/A
1
2
3
4
Interpretation of ABG’s
N/A
1
2
3
4
Administration of nebulizer medications
N/A
1
2
3
4
Oropharyngeal suctioning
N/A
1
2
3
4
Nasotracheal suctioning
N/A
1
2
3
4
Assist with thoracentesis
N/A
1
2
3
4
Set up and assist with chest tube insertion and removal
