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Dialysis Technician

    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

Work Settings

Acute/Inpatient Dialysis

Chronic/Outpatient Dialysis

Dialysis Home Care

Pediatric Dialysis

Apheresis

Plasmapheresis

Set up/Initiate Dialysis Treatment

Bicarbonate Dialysate

Conductivity Testing

Priming Dialyzer

Prep Vascular Access

Fistula Gortex/Bovine Graft

Anticoagulation Management

Apheresis

Plasmapheresis

Cannulating Buttonholes

Continuous Renal Replacement Therapy

Peritoneal Dialysis

Assessment During Dialysis

Vascular Access Function

Arterial and Venous Pressures

Blood Flow Rate

Management of Anticoagulation

Conductivity

Ultra Filtration Calculation

Operation of Myron L. Meter

Administration of Blood and Blood Products

Administration of Mannitol

Sequential Ultrafiltration/PUF

Patient Management

Fluid Overload

Hypotension

Disequilibrium Syndrome

Hyperkalemia

Seizures

Muscle Cramps

Clotted Access/Poor Blood Flow Rate from Catheter

Pyrogenic Reaction

Hemolysis

Air Embolus

Chest Pain

Anemia

Neuropathy

Pericarditis

Filter Blood Leak

Cardiopulmonary Arrest

Anticoagulation Emergencies

Dialysis Equipment

Baxter

Cobe

Fresenius H/K

Gambro

Phoenix

T Machine

Professional Knowledge and Skills

National Patient Safety Goals

Patient Isolation/Infection Prevention

Management of Dialysis Equipment Alarms

Bedside Blood Glucose Monitoring

Pyxis Medication Admin. System

Computerized Charting

Proton Charting Experience

AMI Charting Experience

Ecube Charting Experience

Certifications/Licenses/Registrations

BLS (Exp. Date)

CHT (Exp. Date)

Please read and agree to the statements below by marking the checkbox.

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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