Interventional Radiology Skills Checklist

1 Interventional RadiologySkills Checklist_____XXX-XX-_____Print NameLast 4 of SS #Date CompletedDirectionsPlease circle a value for each question toprovide us and the interested facilities withan assessment of your clinical values confirm your strengths withinyour specialty and assist the facility in theselection process of the 1 - No Experience (has never done or observed) 2 - Requires Training (In-Service) - not performed within last 36 months 3 - Limited Experience (requires assistance or training) - performed within the last 24 months 4 - Experienced (routinely performs without assistance) - performed within the last 12 months 5 - Able to Supervise, Precept and Teach - performed within the last 6 monthsGENERALE xperience ADMIT PATIENT TO PRE PROCEDURE HOLDING12345 PATIENT ASSESSMENTS / OBTAIN FAMILY HISTORY12345 START PERIPHERAL IV12345 COMPLETE PRE-PROCEDURE CHECKLIST12345 TRANSPORT PRE-PROCEDURE PATIENT LAB12345 TRANSPORT POST-PROCEDURE PATIENT LAB12345 TRANSPORT POST-PROCEDURE PATIENT TO UNITS12345 PROCEDURESE xperience CEREBRAL ANGIOGRAM-PREPARE12345 CEREBRAL ANGIOGRAM - ASSIST12345 LOWER EXTREMITY ANGIOGRAM PREPARE12345 LOWER EXTREMITY ANGIOGRAM ASSIST12345 UPPER EXTREMITY ANGIOGRAM PREPARE12345 UPPER EXTREMITY ANGIOGRAM ASSIST12345 ULTRASOUND GUIDED BIOPSY - PREPARE12345 ULTRASOUND GUIDED BIOPSY - ASSIST12345 CT SCAN GUIDED BIOPSY - PREPARE12345_____InitialsVersion.

2 07/03/2012 Page 1 out of 4 Interventional RadiologySkills ChecklistPROCEDURESE xperience CT SCAN GUIDED BIOPSY - ASSIST12345 LIVER BIOPSY AND EMBOLIZATION ASSIST12345 PREPARE / ASSIST W. LINE PLACEMENT-BROVIAC12345 PREPARE /ASSIST W. LINE PLACEMENT GROSHONG12345 PREPARE/ ASSIST W. LINE PLACEMENT-HICKMAN12345 PREPARE & ASSIST W. LINE PLACEMENT-PICC12345 PREPARE & ASSIST W. LINE PLACEMENT PORTACATH12345 TEMP HEMODIALYSIS SHUNT - PREPARE12345 UTERINE FIBROID EMBOLIZATION PREPARE12345 TEMP HEMODIALYSIS SHUNT - ASSIST12345 PERM HEMODIALYSIS SHUNT - PREPARE12345 PERM HEMODIALYSIS SHUNT - ASSIST12345 AV FISTULA / SHUNT DECLOTTING ASSIST12345 VERTEBROPLASTY PREPARE12345 VERTEBROPLASTY ASSIST12345 LUMBAR PUNCTURE - PREPARE12345 LUMBAR PUNCTURE ASSIST12345 MYELOGRAM PREPARE12345 MYELOGRAM ASSIST12345 PROVIDE PATIENT POST PROCEDURES12345 CARDIOVASCULARE xperience ASSES HEART SOUND & PERIPHERAL PULSES12345 INTERPRET ARRHYTHMIAS12345 PERFORM CPR12345 PERFORM DEFIBRILLATION12345 PARTICIPATE / TEAM CPR12345 PULMONARYE xperience ASSESS HEART SOUNDS AN PERIPHERAL PULSES12345 SET UP OXYGEN DEVICES12345 OBTAIN PULSE OXIMETRY12345_____InitialsVersion.

3 07/03/2012 Page 2 out of 4 Interventional RadiologySkills ChecklistPULMONARYE xperience INTERPRET ABG12345 USE AMBUBAG12345 ASSIST WITH INTUBATION12345 ASSIST WITH CHEST TUBE INSERTION12345 NEUROLOGICALE xperience IDENTIFY CHANGE IN CONSCIOUSNESS12345 ASSESS SENSORY, MOTOR & SPEECH12345 ASSESS REFLEXES (BABINSKI, GAG)12345 MEDICATIONSE xperience TITRATE VASOACTIVE DRUGS12345 CALCULATE MCG/MIN / & MCG/KG/MIN12345 USE IV INFUSION PUMP TO CALCULATE DOSES12345 ADMINISTER IV DOPAMINE12345 ADMINISTER IV NITROGLYCERINE12345 ADMINISTER IV DOBUTAMINE (DOBUTREX)12345 ADMINISTER IV LIDOCAINE12345 ADMINISTER IV DILTIAZEM (CARDIZEM)12345 ADMINISTER IV EPINEPHRINE12345 ADMINISTER IV ATROPINE12345 ADMINISTER IV HEPARIN12345 ADMINISTER IV BENZODIAZEPINES ( )12345 ADMINISTER IV PROPOFOL (DIPRIVAN)12345 ADMIN. IV NEUROMUSCULAR BLOCKING AGENTS12345 ADMINISTER IV NARCOTICS (MORPHINE, FENTANYL)12345 PAIN / WOUND MANAGEMENTE xperience ASSESS PAIN LEVEL TOLERANCE12345 CARE OF PATIENT WITH ANESTHESIA / ANALGESIA12345 CARE OF PATIENT WITH IV SEDATION12345 CARE OF PATIENT WITH NARCOTIC ANALGESIA12345 CARE OF PATIENT WITH PCA PUMP12345_____InitialsVersion: 07/03/2012 Page 3 out of 4 The information represented above is true and correct to the best of my knowledge.

4 I also authorizeSpecialty Professional Services, Corp to share the above Skills Checklist with its facility clients. Interventional RadiologySkills ChecklistPAIN / WOUND MANAGEMENTE xperience ASSESS SURGICAL WOUNDS WITH DRAINS12345 ASSESS SURGICAL WOUNDS W/OUT DRAINS12345 CARE OF PATIENT W/STERILE DRESSING CHANGES12345 CARE OF PATIENT W/FEMOSTOP12345 ASSESSMENT OF VASOSEAL, ANGIOSEAL12345 AGE APPROPRIATE CAREE xperience NEWBORN (BIRTH-30 DAYS)12345 INFANT (30 DAYS - 1 YEAR)12345 TODDLER (1 - 3 YEARS)12345 PRESCHOOLER (3 - 5 YEARS)12345 SCHOOL AGE (5 - 12 YEARS)12345 ADOLESCENTS (12 - 18 YEARS)12345 YOUNG ADULTS (18 - 39 YEARS)12345 MIDDLE ADULTS (39 - 64 YEARS)12345 OLDER ADULTS (64+ YEARS)12345 _____SignatureDate CompletedFax: 718-225-9421 Version: 07/03/2012 Page 4 out of 4