Name:
Email:
LAST 4 OF SSN:
This checklist was electronically signed on (Today’s date)
This checklist is designed to guide our client facilities in assessing your proficiency in your nursing specialty. Please use the scale provided to indicate your level of experience and expertise in each of the areas listed below.
Skill Level Indicator:
★ = No Experience
★★ = Requires Training
★★★ = Capable with Supervision
★★★★ = Capable Independently
Cardiac & Diagnostic Cardiac Catheter
Cerebral Angiography
Peripheral Angiography
Simple Angioplasty
Complex Angioplasty
Arterial Puncture and Cannulation
Cardioversion
Central Line Insertion
Simple/Basic Intracardiac Readings
Limited Stimulation Studies
Arrythmic Induction and Mapping
Radiofrequency Ablation for Arrhythmias
Moderate Sedation
Pericardiocentesis
Spinal Tap
Pacemakers: Temporary
Pacemakers: AICD
Pacemakers: Complete
Pacemakers: Lead Position Only
Pacemakers: Permanent
Rotational Atherectomy
Stent Implantation (Non Cardiac – Non Cerebral)
Stent Implantation: Peripheral
Covered Stent Placement - Peripheral
Stent Implantation: Renal
Swan_Ganz Catheterization
Thoracentesis
Trans Esophageal Echocardiography (TEE)
TTE Interpretation
Stress Testing
Tilt Table
Intra-Aortic Balloon Pump Insertion
Cardiac Cathertization
Stent: Coronary
Intravascular Ultrasound
Cutting Balloon Atherectomy
Electrophysiology Studies
Radiofrequency Ablation
Closed Operation on Heart
Open Heart under Hypothermia
Open Heart requiring Partial By-Pass
Open Heart Requiring Oxygenator
Chest Wall Reconstruction
I hereby certify that ALL information I have provided on this skills checklist and all other documentation is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.
