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Critical Care

    Instruction

    Please rate your experience / frequency (within the last year) using the scale (check the appropriate boxes below)

  • 0 = No theory and/or experience
  • 1 = Limited experience/need supervision and/or support
  • 2 = Experienced/minimal support needed to perform)
  • 3 = Proficient/can perform independently
  • 4 = Expert/very experienced in the field
Personal Information

Full Name

Email

Phone number

Last 4 of Social Security Number

Date

Cardiac

Acute Coronary Syndrome

Congestive Heart Failure

Cardiogenic Shock

Cardiac Tamponade

Heart Sounds

Immediate Post-Op Open Heart (directly from OR)

Immediate Post-Op Open Heart (NOT directly from OR)

Heart Transplant

Open Chest Emergency

Sheath Removal

Pacemaker - Temporary/Permanent

Pacemaker - Epicardial

Hemodynamic Monitoring

SVO2 Monitoring

Intra-Aortic Balloon Pump

Ventricular Assist Device

ECMO

Pulmonary

Respiratory Failure

ARDS

Pneumothorax

Pulmonary Embolism

Pulmonary Edema

Fresh Tracheostomy

Chest Trauma

Post Thoracic Surgery

Lung Transplant

Intubation/Extubation

Modes of Ventilation (AC/PC/SIMV/CPAP)

Nitric Oxide

Interpretation of Arterial Blood Gases

Chest Tube Placement And Management

Neurological And Psychiatric

Stroke Scale Assessment

CVA

Brain Injury

Post Craniotomy

Spinal Cord Injury

Seizure Disorders

ICP Monitoring

Hypothermia Protocol

Substance Withdrawal

Suicide Precautions

Gastrointestinal

GI Bleeding

GI Surgery

Liver Failure

Pancreatitis

Liver Transplant

Pancreas Transplant

Renal/Genitourinary

Renal Failure

Renal Surgery

TURP

Renal Transplant

Arteriovenous Fistula/Shunt

Nephrostomy Tubes

Peritoneal Dialysis

Continuous Renal Replacement Therapy

Endocrine Metabolic

Diabetes - Hypo/Hyperglycemic Crisis

Diabetic Ketoacidosis

Pituitary Disorders

IV Insulin Protocols

Indwelling Insulin Pumps

Medications

Anti-Arrhythmics

Anticoagulants (IV, oral, and injection)

Anti-Hypertensives

Anti-Psychotics

Anti-Seizure Medications

Benzodiazepines

Continuous IV Paralytics

Continuous IV Sedation

Procedural Sedation – Administration

Diuretics

Emergency Medications

Inhaled Medications

Insulin

IV Vasopressors

Narcotics/Opioid Analgesics (IV, oral, and injection)

Nitrates (Oral and Topical)

Non-Opioid Analgesics (IV, Oral, and Injection)

Reversal Agents

Steroids (IV, Oral, Inhaled)

Automated Medication Dispensing (i.e. Pyxis, Omnicell)

IV Therapy

Starting IVs

Central Line Blood Draws

Central Line/Implanted Line Care

TPN And Lipids

Blood Product Administration

Administration of Chemotherapy

Cardiac Monitoring And Emerg. Response

Dysrhythmia Interpretation

Dysrhythmia Management

Obtain 12 Lead EKG

Interpret 12 Lead EKG

Management of Cardiac Arrest

Shock Management

Malignant Hyperthermia

Multisystem Organ Failure

Professional Knowledge And Skills

National Patient Safety Goals/Core Measures

Fall Risk Assessment/Preventiont

Pressure Ulcer Risk Assessment/Prevention

Restraints/Use of Least Restrictive Device

Patient/Family Teaching

Age Specific/Population-Based Care

Isolation Precautions

Infection Prevention

Pain Assessment and Management

Charge Experience

Interpretation and Communication of Lab Values

Specialty Beds

EMR

Epic

Cerner

Eclipsys

McKesson

Meditech

Other Computerized System

Computerized Physician Order Entry

Bar Coding for Medication Administration

EMR Conversion

Certifications

BLS (Exp. Date)

ACLS (Exp. Date)

PALS (Exp. Date)

TNCC (Exp. Date)

CCRN (Exp. Date)

Telemetry Certificate/Course (Date taken)

Critical Care Course (Date taken)

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I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Company to release this Skills Checklist to the Client facilities in relation to consideration of employment as a Healthcare Professional with those facilities.

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