INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST

(CLINICAL/NON-CLINICAL)

ST. ELIZABETH MEDICAL CENTER

Associate Department Cath Lab Recovery

Job Title CCR Nurse Evaluation Period

Instructions: Record each activity to be evaluated. Assessment of “Meets Expectations” indicates the individual meets the performance expectations for the skill/competency. A rating of “Does Not Meet” requires documentation of an action plan for correction, a repeat evaluation, and a competency demonstration within 30-90 days. Note any relevant comments in the adjacent column.

SKILL/PROCEDURE/EQUIPMENT

/ DATE REVIEWED/
REVIEWED BY
(Initials)* / M = MEETS EXPECTATIONS
DNM = DOES NOT MEET EXPECTATIONS / COMMENTS/ACTION
PLAN
COMMUNICATES AND DIRECTS
PERTINENT INFORMATION TO THE
HEALTH CARE TEAM:
Scheduling of outpatients
/ M DNM N/A
Scheduling of inpatients / M DNM N/A
Voice mailbox / M DNM N/A
Central scheduling module / M DNM N/A
Schedule log / M DNM N/A
Beepers and call / M DNM N/A
KNOWS PROPER USAGE OF STERILE
SUPPLIES
Defib pads / M DNM N/A
Closure devices / M DNM N/A
KNOWS PROPER USAGE AND TROUBLE SHOOTING OF EQUIPMENT - CARDIAC CATH LAB:
ACT / M DNM N/A
Propaqs / M DNM N/A
Witt monitor / M DNM N/A
Lifepak / M DNM N/A
Zoll / M DNM N/A
Demand pulse generators / M DNM N/A
Intra-aortic balloon pump / M DNM N/A
Defib-implant supporter / M DNM N/A

*Skills specific to licensure are to be reviewed by someone of like discipline.

1/06

INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST

ST. ELIZABETH MEDICAL CENTER

SKILL/PROCEDURE/EQUIPMENT

/ DATE REVIEWED/
REVIEWED BY
(Initials)* / M = MEETS EXPECTATIONS
DNM = DOES NOT MEET EXPECTATIONS / COMMENTS/ACTION
PLAN
Ultrasound stethoscope / M DNM N/A
Transducers / M DNM N/A
IDENTIFIES THE FOLLOWING
RHYTHMS
Sinus rhythm / M DNM N/A
Sinus tachycardia / M DNM N/A
Atrial fibrillation / M DNM N/A
Atrial flutter / M DNM N/A
Junctional rhythm / M DNM N/A
Supraventricular tachycardia / M DNM N/A
Premature ventricular contraction / M DNM N/A
Premature atrial contraction / M DNM N/A
Premature junctional contraction / M DNM N/A
Bigeminy, trigeminy

Ventricular tachycardia / M DNM N/A
M DNM N/A
Ventricular fibrillation / M DNM N/A
Second degree AV block type I / M DNM N/A
Second degree AV block type II / M DNM N/A
Third degree AV block / M DNM N/A
Paced rhythm / M DNM N/A
Captured paced beat / M DNM N/A
Failure to capture / M DNM N/A
Fusion beat / M DNM N/A
Failure to sense / M DNM N/A
COMPLETES DOCUMENTATION PER
PROCEDURE:
Admission documents
Uses Witt system to document pre & post care / M DNM NA
M DNM N/A
Discharge criteria from the Cardiac Cath Lab
and reports to various units/facilities / M DNM N/A

INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST

ST. ELIZABETH MEDICAL CENTER

SKILL/PROCEDURE/EQUIPMENT

/ DATE REVIEWED/
REVIEWED BY
(Initials)* / M = MEETS EXPECTATIONS
DNM = DOES NOT MEET EXPECTATIONS / COMMENTS/ACTION
PLAN
OBSERVES SAFETY:
Radiation protection safety / M DNM N/A
Allergy precautions / M DNM N/A
OBSERVES INFECTION CONTROL:
Proper procedure for IV starts / M DNM N/A
Proper cleaning of equipment / M DNM N/A
CAN ASSIST WITH PROCEDURES/CARE FOR PATIENT PRE & POST
Daily preparation of cath lab recovery / M DNM N/A
Recovery of patient / M DNM N/A
Hemodynamic monitoring / M DNM N/A
Conscious sedation / M DNM N/A
Lab results / M DNM N/A
Coronary Angiograms / M DNM N/A
Cardioversions / M DNM N/A
Renals / M DNM N/A
EPS/Ablations / M DNM N/A
Radial/Femoral/Brachial approach / M DNM N/A
Left heart cath / M DNM N/A
Right heart cath / M DNM N/A
PTCRA / M DNM N/A
Coronary stents / M DNM N/A
Renal stents / M DNM N/A
Temporary pacemaker / M DNM N/A
Intravascular ultrasound / M DNM N/A
Pulmonary artery catheters / M DNM N/A
Pericardiocentesis / M DNM N/A
Code blue / M DNM N/A

INITIAL SKILL/EQUIPMENT COMPETENCY CHECKLIST

ST. ELIZABETH MEDICAL CENTER

SKILL/PROCEDURE/EQUIPMENT / DATE REVIEWED/
REVIEWED BY
(Initials)* / M = MEETS EXPECTATIONS
DNM = DOES NOT MEET EXPECTATIONS / COMMENTS/ACTION
PLAN
Removal of introducers / M DNM N/A
Manual Compression / M DNM N/A
Mechanical Compression / M DNM N/A
Closure device / M DNM N/A
Reveal implant and explant / M DNM N/A
Post mortem care / M DNM N/A
Closing of recovery area / M DNM N/A
Pyxis / M DNM N/A
Emergency drugs / M DNM N/A
2B 3A agents / M DNM N/A
Angiomax / M DNM N/A
Par Level / M DNM N/A
Bicarb infusions / M DNM N/A

*Skills specific to licensure are to be reviewed by someone of like discipline.

Initials / Signature / Title / Initials / Signature / Title

Date: Associate Signature:

Date: Manager Signature:

To be completed yearly at the time of performance appraisal.

“I am still currently up-to-date on the above mentioned procedures.”

Associate Sign Date Mgr Sign

Associate Sign Date Mgr Sign

Associate Sign Date Mgr Sign

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