Download skill/procedure/equipment - St. Elizabeth Medical Center

INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST
(CLINICAL/NON-CLINICAL)
ST. ELIZABETH MEDICAL CENTER
Associate
Job Title
Department
CCR Nurse
Cath Lab Recovery
Evaluation Period
Instructions: Record each activity to be evaluated. Assessment of “Meets Expectations” indicates the individual meets
the performance expectations for the skill/competency. A rating of “Does Not Meet” requires documentation of an action
plan for correction, a repeat evaluation, and a competency demonstration within 30-90 days. Note any relevant
comments in the adjacent column.
DATE
M = MEETS
SKILL/PROCEDURE/EQUIPMENT
COMMENTS/ACTION
REVIEWED/
EXPECTATIONS
PLAN
REVIEWED BY
DNM = DOES NOT MEET
(Initials)*
EXPECTATIONS
COMMUNICATES AND DIRECTS
PERTINENT INFORMATION TO THE
HEALTH CARE TEAM:
Scheduling of outpatients
M
DNM
N/A
Scheduling of inpatients
M
DNM
N/A
Voice mailbox
M
DNM
N/A
Central scheduling module
M
DNM
N/A
Schedule log
M
DNM
N/A
Beepers and call
M
DNM
N/A
KNOWS PROPER USAGE OF STERILE
SUPPLIES
Defib pads
M
DNM
N/A
Closure devices
M
DNM
N/A
KNOWS PROPER USAGE AND TROUBLE
SHOOTING OF EQUIPMENT - CARDIAC
CATH LAB:
ACT
M
DNM
N/A
Propaqs
M
DNM
N/A
Witt monitor
M
DNM
N/A
Lifepak
M
DNM
N/A
Zoll
M
DNM
N/A
Demand pulse generators
M
DNM
N/A
Intra-aortic balloon pump
M
DNM
N/A
Defib-implant supporter
M
DNM
N/A
*Skills specific to licensure are to be reviewed by someone of like discipline.
1
1/06
INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST
ST. ELIZABETH MEDICAL CENTER
SKILL/PROCEDURE/EQUIPMENT
DATE
REVIEWED/
REVIEWED BY
(Initials)*
M = MEETS
EXPECTATIONS
DNM = DOES NOT MEET
EXPECTATIONS
Ultrasound stethoscope
M
DNM
N/A
Transducers
M
DNM
N/A
IDENTIFIES THE FOLLOWING
RHYTHMS
Sinus rhythm
M
DNM
N/A
Sinus tachycardia
M
DNM
N/A
Atrial fibrillation
M
DNM
N/A
Atrial flutter
M
DNM
N/A
Junctional rhythm
M
DNM
N/A
Supraventricular tachycardia
M
DNM
N/A
Premature ventricular contraction
M
DNM
N/A
Premature atrial contraction
M
DNM
N/A
Premature junctional contraction
M
DNM
N/A
Bigeminy, trigeminy
M
DNM
N/A
Ventricular tachycardia
M
DNM
N/A
Ventricular fibrillation
M
DNM
N/A
Second degree AV block type I
M
DNM
N/A
Second degree AV block type II
M
DNM
N/A
Third degree AV block
M
DNM
N/A
Paced rhythm
M
DNM
N/A
Captured paced beat
M
DNM
N/A
Failure to capture
M
DNM
N/A
Fusion beat
M
DNM
N/A
Failure to sense
M
DNM
N/A
COMPLETES DOCUMENTATION PER
PROCEDURE:
Admission documents
M
DNM
NA
Uses Witt system to document pre & post care
M
DNM
N/A
Discharge criteria from the Cardiac Cath Lab
and reports to various units/facilities
M
DNM
N/A
2
COMMENTS/ACTION
PLAN
INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST
ST. ELIZABETH MEDICAL CENTER
SKILL/PROCEDURE/EQUIPMENT
DATE
REVIEWED/
REVIEWED BY
(Initials)*
M = MEETS
EXPECTATIONS
DNM = DOES NOT MEET
EXPECTATIONS
OBSERVES SAFETY:
Radiation protection safety
M
DNM
N/A
Allergy precautions
M
DNM
N/A
OBSERVES INFECTION CONTROL:
Proper procedure for IV starts
M
DNM
N/A
Proper cleaning of equipment
M
DNM
N/A
CAN ASSIST WITH PROCEDURES/CARE
FOR PATIENT PRE & POST
Daily preparation of cath lab recovery
M
DNM
N/A
Recovery of patient
M
DNM
N/A
Hemodynamic monitoring
M
DNM
N/A
Conscious sedation
M
DNM
N/A
Lab results
M
DNM
N/A
Coronary Angiograms
M
DNM
N/A
Cardioversions
M
DNM
N/A
Renals
M
DNM
N/A
EPS/Ablations
M
DNM
N/A
Radial/Femoral/Brachial approach
M
DNM
N/A
Left heart cath
M
DNM
N/A
Right heart cath
M
DNM
N/A
PTCRA
M
DNM
N/A
Coronary stents
M
DNM
N/A
Renal stents
M
DNM
N/A
Temporary pacemaker
M
DNM
N/A
Intravascular ultrasound
M
DNM
N/A
Pulmonary artery catheters
M
DNM
N/A
Pericardiocentesis
M
DNM
N/A
Code blue
M
DNM
N/A
3
COMMENTS/ACTION
PLAN
INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST
ST. ELIZABETH MEDICAL CENTER
SKILL/PROCEDURE/EQUIPMENT
DATE
REVIEWED/
REVIEWED BY
(Initials)*
M = MEETS
EXPECTATIONS
DNM = DOES NOT MEET
EXPECTATIONS
Removal of introducers
M
DNM
N/A
Manual Compression
M
DNM
N/A
Mechanical Compression
M
DNM
N/A
Closure device
M
DNM
N/A
Reveal implant and explant
M
DNM
N/A
Post mortem care
M
DNM
N/A
Closing of recovery area
M
DNM
N/A
Pyxis
M
DNM
N/A
Emergency drugs
M
DNM
N/A
2B 3A agents
M
DNM
N/A
Angiomax
M
DNM
N/A
Par Level
M
DNM
N/A
Bicarb infusions
M
DNM
N/A
COMMENTS/ACTION
PLAN
*Skills specific to licensure are to be reviewed by someone of like discipline.
Initials
Signature
Title
Initials
Date:
Associate Signature:
Date:
Manager Signature:
Signature
To be completed yearly at the time of performance appraisal.
“I am still currently up-to-date on the above mentioned procedures.”
Associate Sign
Date
Mgr Sign
Associate Sign
Date
Mgr Sign
Associate Sign
Date
Mgr Sign
4
Title
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