CYNET_SYSTEMS_MAIN_LOGO.gif   CERTIFIED REGISTERED NURSE ANESTHETIST 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) PROCEDURES 1 2 3 4  
Angina  
ENT  
Neurosurgical  
Obstetrics  
Open Heart  
Orthopedics  
Plastics  
Trauma  
Vascular  
Rating Stars (Click) MEDICATIONS 1 2 3 4  
Accessory Medications  
Adjuvant Medications  
Blood Products  
Fluids  
Ketamine  
Methohexital  
Nitrous Oxide  
Sodium Thiopental  
Valium  
Versed  
Rating Stars (Click) AIRWAY MANAGEMENT 1 2 3 4  
Cardiovascular Status  
COPA  
Endotracheal Intubation  
Fiber Optic Intubation  
Nasal Intubation  
Neuromuscular Status and Function  
Oxygentation  
Patient Positioning  
Ventilation  
Rating Stars (Click) ANESTHESIA CARE 1 2 3 4  
Infection Control Practices  
Interpretation of Lab Studies  
IV General Anesthesia  
IV Maintenance  
Mask Induction and Maintenance  
Total IV Anesthesia  
Local  
Caudal  
Epidural  
Subarachnoid Block  
Nerve Block  
Intercostal Block  
Intravenous Regional  
Local Infiltration Block  
Major  
Plexus  
Retrobulbar  
Transtracheal Block  
Obtaining Accurate Pre-anesthesia Assessment  
Recommend Appropriate Diagnostic Studies  
Rating Stars (Click) WORK SETTINGS 1 2 3 4  
Acute Care Hospital  
Dentist Office  
Plastic Surgery Center  
Private Practice Office Setting  
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)