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
Telemetry Unit (located on the unit)
Remote Telemetry Office
Skin prep
Lead Placement - 3 Lead
Lead Placement - 5 Lead
Set up MCL1
Set up Lead II
Set up 12 Lead ECG
Normal Sinus Rhythm
Sinus Bradycardia/Sinus Tachycardia
Premature Atrial Contractions
Atrial Flutter
Atrial Fibrillation
Junctional Rhythms
PVC - Unifocal/Multifocal
PVC- Bigeminy/Trigeminy/Coupling
Ventricular Tachycardia
Ventricular Fibrillation
1st Degree Heart Block
2nd Degree Heart Block Type I
2nd Degree Heart Block Type II
3rd Degree Heart Block
Sinus Arrest
Asystole
Bundle Branch Block
Paced Rhythms - Atrial/Ventricular/AV
Pacemaker Misfire
Pacemaker- Failure to Capture
Measure Cardiac Rate
Measure Cardiac Intervals (PR, QRS, ST, etc.)
GE
Phillips
Spacelabs
Other (specify)
Cardiac Arrest Protocol
Computerized Charting
Epic
Cerner
Eclipsys
McKesson
Meditech
Other Computerized System
Computerized Physician Order Entry
Bar Coding for Medication Administration
Newborn/Neonatal (birth – 30 days)
Infant (30 days-1 year)
Toddler (1-3 years)
Preschool (3-5 years)
School Age Children (5-12 years)
Adolescent (12-17 years)
Young Adults (18-44 years)
Middle Adults (45-64 years)
Older Adults (>65 years)
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.
