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)

2 - 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

3 EXTREMITY ANGIOGRAM ASSIST12345 ULTRASOUND GUIDED BIOPSY - PREPARE12345 ULTRASOUND GUIDED BIOPSY - ASSIST12345 CT SCAN GUIDED BIOPSY - PREPARE12345_____InitialsVersion: 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

4 PERFORM CPR12345 PERFORM DEFIBRILLATION12345 PARTICIPATE / TEAM CPR12345 PULMONARYE xperience ASSESS HEART SOUNDS AN PERIPHERAL PULSES12345 SET UP OXYGEN DEVICES12345 OBTAIN PULSE OXIMETRY12345_____InitialsVersion: 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)

5 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.

6 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)

7 12345 OLDER ADULTS (64+ YEARS)12345 _____SignatureDate CompletedFax: 718-225-9421 Version: 07/03/2012 Page 4 out of 4