Telemetry Skills Checklist - Specialty Professional Services

1 Telemetry Skills Checklist _____ XXX-XX-_____ _____. Print Name Last 4 of SS # Date Completed Directions Experience Please circle a value for each question to 1 - No Experience (has never done or observed). provide us and the interested facilities with 2 - Requires Training (In-Service) - not performed within last 36 months 3 - Limited Experience (requires assistance or training) - performed within the last 24 months an assessment of your clinical experience. 4 - Experienced (routinely performs without assistance) - performed within the last 12 months These values confirm your strengths within 5 - Able to Supervise, Precept and Teach - performed within the last 6 months your Specialty and assist the facility in the selection process of the healthcare Professional .

2 NEUROLOGY Experience MAGNESIUM SULFATE 1 2 3 4 5. LASIX / MANNITOL 1 2 3 4 5. PHENOBARBITAL 1 2 3 4 5. DILANTIN 1 2 3 4 5. VERSED 1 2 3 4 5. DECADRON 1 2 3 4 5. MORPHINE SULPHATE 1 2 3 4 5. PRE/POST NEURO SURGERY 1 2 3 4 5. NEURO INJURY /TRAUMA 1 2 3 4 5. POST-OP AV-SHUNTS 1 2 3 4 5. CVA / TIA 1 2 3 4 5. CRANIAL HEMORRHAGE 1 2 3 4 5. CRANIAL HEMATOMA 1 2 3 4 5. HALO VEST 1 2 3 4 5. HEAD INJURY/TRAUMA 1 2 3 4 5. ICP MONITOR 1 2 3 4 5. SEIZURES 1 2 3 4 5. _____. Version: 07/03/2012 Page 1 out of 7. Initials Telemetry Skills Checklist NEUROLOGY Experience MULTIPLE SCLEROSIS 1 2 3 4 5. OVERDOSE 1 2 3 4 5. LUMBAR PUNCTURE ASSISTANCE 1 2 3 4 5. SEIZURE PRECAUTIONS 1 2 3 4 5. NEURO ASSESSMENT 1 2 3 4 5. GLASCOW COMA SCALE 1 2 3 4 5.

3 ATROVENT 1 2 3 4 5. TEMPORARY PACEMAKERS 1 2 3 4 5. LOWER GI BLEED 1 2 3 4 5. RESPIRATORY Experience BRONKOSOL 1 2 3 4 5. ALBUTEROL 1 2 3 4 5. ATROVENT 1 2 3 4 5. ALUPENT 1 2 3 4 5. AMINOPHYLLINE 1 2 3 4 5. VENTOLIN 1 2 3 4 5. CORTICOSTEROIDS 1 2 3 4 5. PRE/POST THORACIC SURGERY 1 2 3 4 5. TRACHEOSTOMY 1 2 3 4 5. COPD 1 2 3 4 5. PNEUMONIA 1 2 3 4 5. PULMONAY EDEMA 1 2 3 4 5. EMPHYSEMA 1 2 3 4 5. TUBERCULOSIS 1 2 3 4 5. PNEUMOTHORAX 1 2 3 4 5. PULSE OXIMETRY 1 2 3 4 5. PULMONARY EMBOLISM 1 2 3 4 5. CHEST TUBES/PLEURAVAC 1 2 3 4 5. OXYGEN THERAPY 1 2 3 4 5. ASTHMA 1 2 3 4 5. _____. Version: 07/03/2012 Page 2 out of 7. Initials Telemetry Skills Checklist RESPIRATORY Experience ORAL SUCTIONING 1 2 3 4 5. THORACENTESIS 1 2 3 4 5.

4 ARDS 1 2 3 4 5. PARACENTESIS 1 2 3 4 5. INHALATION INJURIES 1 2 3 4 5. INCENTIVE SABG INTERPRETATION 1 2 3 4 5. USE OF IPPB 1 2 3 4 5. AMBUING TECHNIQUES 1 2 3 4 5. NASOTRACHEAL SUCTIONING 1 2 3 4 5. AIRWAY ESTABLISHMENT 1 2 3 4 5. CARDIOVASCULAR Experience QUINIDINE 1 2 3 4 5. LIDOCAINE 1 2 3 4 5. DIGOXIN 1 2 3 4 5. ANDRENERGICS 1 2 3 4 5. DIURETICS 1 2 3 4 5. NTG 1 2 3 4 5. MORPHINE TITRATE 1 2 3 4 5. BETA BLOCKERS 1 2 3 4 5. INDERAL 1 2 3 4 5. THROMBOLYTICS 1 2 3 4 5. ATROPINE 1 2 3 4 5. VASOPRESSORS 1 2 3 4 5. NIPRIDE 1 2 3 4 5. NITRATES 1 2 3 4 5. DOPAMINE 1 2 3 4 5. CALCIUM CHANNEL BLOCKERS 1 2 3 4 5. PRONESTYL 1 2 3 4 5. VERAPAMIL 1 2 3 4 5. ANTIARRYTHMICS 1 2 3 4 5. _____. Version: 07/03/2012 Page 3 out of 7.

5 Initials Telemetry Skills Checklist CARDIOVASCULAR Experience ANTICOAGULANTS 1 2 3 4 5. CHF 1 2 3 4 5. PRE/POST CARDIAC SURGERY 1 2 3 4 5. PERMANENT PACEMAKERS 1 2 3 4 5. ANGINA 1 2 3 4 5. CARDIOVERSION 1 2 3 4 5. POST MI 1 2 3 4 5. A-LINE SET UP 1 2 3 4 5. EXTERNAL PACEMAKERS 1 2 3 4 5. SWAN GANZ SET UP 1 2 3 4 5. PRE/POST CARDIAC CATH 1 2 3 4 5. CARDIAC ARREST 1 2 3 4 5. CVP LINES 1 2 3 4 5. OPEN STERNAL WOUND 1 2 3 4 5. ABDOMINAL AORTIC ANEURYSM 1 2 3 4 5. FEMORAL SHEATH REMOVAL 1 2 3 4 5. ARRHYTHMIA INTERPRETATION 1 2 3 4 5. HEMODYNAMIC MONITORING 1 2 3 4 5. CARDIOGENIC SHOCK 1 2 3 4 5. STENT PROCEDURES 1 2 3 4 5. VASCULAR Experience PRE/POST VASCULAR SURGERY 1 2 3 4 5. NORMAL SERUM LAB VALUES 1 2 3 4 5. PERIPHERAL PULSES 1 2 3 4 5.

6 PICC LINES 1 2 3 4 5. SUBCUTANEOUS CENTRAL LINES 1 2 3 4 5. BLOOD / BLOOD BYPRODUCTS 1 2 3 4 5. HEPARIN LOCKS 1 2 3 4 5. ULTRASONIC DOPPLER 1 2 3 4 5. INFUSION LINES 1 2 3 4 5. _____. Version: 07/03/2012 Page 4 out of 7. Initials Telemetry Skills Checklist VASCULAR Experience HEPARIN DRIPS 1 2 3 4 5. SICKLE CELL ANEMIA 1 2 3 4 5. PERITONEAL DIALYSIS 1 2 3 4 5. HEMODIALYSIS 1 2 3 4 5. THROMBOPHLEBITIS 1 2 3 4 5. FLUID OVERLOAD 1 2 3 4 5. HYPERALIMENTATION 1 2 3 4 5. IV CUTDOWN ASSISTANCE 1 2 3 4 5. DVT'S 1 2 3 4 5. AIR OCCLUSION DRESSING 1 2 3 4 5. HICKMAN CATHETERS 1 2 3 4 5. BROVIAC CATHETERS 1 2 3 4 5. RENAL & GASTROURINARY Experience NEPHROSTOMY TUBES 1 2 3 4 5. NEPHRECTOMY 1 2 3 4 5. PERITONITIS 1 2 3 4 5. FISTULAS / SHUNTS 1 2 3 4 5.

7 FLUID / ELECTROLYTE DEPLETION 1 2 3 4 5. ACUTE RENAL FAILURE 1 2 3 4 5. SUPRAPUBIC TUBES 1 2 3 4 5. RENAL TRAUMA 1 2 3 4 5. GU IRRIGATIONS 1 2 3 4 5. INSERTION / FOLEY CATHETER 1 2 3 4 5. RENAL TRANSPLANT 1 2 3 4 5. 1 2 3 4 5. CHRONIC RENAL FAILURE 1 2 3 4 5. RENAL SURGERY 1 2 3 4 5. GASTROINTESTINAL Experience HEPATITIS 1 2 3 4 5. PANCREATITIS 1 2 3 4 5. _____. Version: 07/03/2012 Page 5 out of 7. Initials Telemetry Skills Checklist GASTROINTESTINAL Experience UPPER GI BLEED 1 2 3 4 5. BOWEL OBSTRUCTION 1 2 3 4 5. POST SURGICAL DRAINS 1 2 3 4 5. PARALYTIC ILEUS 1 2 3 4 5. LIVER TRANSPLANT 1 2 3 4 5. ESOPHAGEAL BLEEDS 1 2 3 4 5. PRE/POST ABDOMINAL SURGERY 1 2 3 4 5. WHIPPLE PROCEDURE 1 2 3 4 5. ERCP 1 2 3 4 5. NG TUBE INSERTION/REMOVAL 1 2 3 4 5.

8 GASTROSTOMY TUBE 1 2 3 4 5. ENTEROSTOMAL CARE 1 2 3 4 5. JEJUNOSTOMY TUBE 1 2 3 4 5. ORTHOPEDIC Experience LAMINECTOMY 1 2 3 4 5. PRE/POST ORTHOPEDIC SURGERY 1 2 3 4 5. SKELETAL TRACTION 1 2 3 4 5. OSTEOMYELITIS 1 2 3 4 5. CAST CARE 1 2 3 4 5. K-WIRES/STEINMAN PINS 1 2 3 4 5. TOTAL JOINT REPLACEMENT 1 2 3 4 5. TRACTION MAINTENANCE 1 2 3 4 5. ORTHO TRAUMA 1 2 3 4 5. AMPUTATION 1 2 3 4 5. HALO TRACTION 1 2 3 4 5. SPIKA CAST 1 2 3 4 5. FRACTURES 1 2 3 4 5. BUCKS EXTENSION 1 2 3 4 5. MISCELLANEOUS Experience HIV INFECTION 1 2 3 4 5. _____. Version: 07/03/2012 Page 6 out of 7. Initials Telemetry Skills Checklist MISCELLANEOUS Experience ONCOLOGY 1 2 3 4 5. CHEMOTHERAPY 1 2 3 4 5. DELIRIUM TREMERS 1 2 3 4 5. ACCUCHECK 1 2 3 4 5.

9 AIDS 1 2 3 4 5. ISOLATION TECHNIQUES 1 2 3 4 5. BURN PATIENTS 1 2 3 4 5. DIABETIC TEACHING 1 2 3 4 5. PATIENT TEACHING 1 2 3 4 5. ENDOMETRIOSIS 1 2 3 4 5. HYSTERECTOMY 1 2 3 4 5. MASTECTOMY 1 2 3 4 5. TUBAL LIGATION 1 2 3 4 5. ECTOPIC PREGNANCY 1 2 3 4 5. AGE APPROPRIATE CARE Experience NEWBORN (BIRTH-30 DAYS) 1 2 3 4 5. INFANT (30 DAYS - 1 YEAR) 1 2 3 4 5. TODDLER (1 - 3 YEARS) 1 2 3 4 5. PRESCHOOLER (3 - 5 YEARS) 1 2 3 4 5. SCHOOL AGE (5 - 12 YEARS) 1 2 3 4 5. YOUNG ADULTS (12 - 18 YEARS) 1 2 3 4 5. YOUNG ADULTS (18 - 39 YEARS) 1 2 3 4 5. MIDDLE ADULTS (39 - 64 YEARS) 1 2 3 4 5. OLDER ADULTS (64+ YEARS) 1 2 3 4 5. The information represented above is true and correct to the best of my knowledge. I also authorize Specialty Professional Services , Corp to share the above Skills Checklist with its facility clients.

10 _____ _____. Signature Date Completed Fax: 718-225-9421 Version: 07/03/2012 Page 7 out of 7.