CYNET_SYSTEMS_MAIN_LOGO.gif   Cardiac Monitor Technician Skills Checklist
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group 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.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) EXPERIENCE IN THE FOLLOWING SETTING(S) 1 2 3 4  
Telemetry Unit (located on the unit)   
Remote Telemetry Office   
  # Monitors Responsible For  
Rating Stars (Click) PATIENT/ EQUIPMENT PREPARATION 1 2 3 4  
Skin prep   
Lead Placement - 3 Lead   
Lead Placement - 5 Lead   
Set up MCL1   
Set up Lead II   
Set up 12 Lead ECG  
Rating Stars (Click) INTERPRET THE FOLLOWING RHYTHMS 1 2 3 4  
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.)  
Rating Stars (Click) MONITORING SYSTEMS USED 1 2 3 4  
GE  
Phillips   
Spacelabs   
Other (specify)   
Other (specify)   
Rating Stars (Click) MISCELLANEOUS 1 2 3 4  
Cardiac Arrest Protocol   
Computerized Charting  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
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)