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Perfusionist Skills
Checklist
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NAME
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EMAIL
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LAST 4 OF SSN
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DATE
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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.
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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.
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Proficiency Scale:
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1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
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Rating Stars (Click)
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CARDIOVASCULAR
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1
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2
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3
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4
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Assessment of Heart Sounds
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Cardiac Rehab / Patient
Teaching
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Controlled Cardioversions
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CVP Monitoring via Water
Manometer
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Electrophysiology Studies
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Emergency Defibrillato
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Interpret 12-Lead EKG
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Interpret Basic Arrhythmias
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Interpretation of Coag Lab
Results
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Interpretation of Cardiac
& Iso Enzymes
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Rating Stars
(Click)
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RADIAL ARTERIAL LINES
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1
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2
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3
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4
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Set Up
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Monitor
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Maintenance
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Complications
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Discontinuing
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Thrombolytic Studies
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Rating Stars
(Click)
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COMPUTERIZED CHARTING
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1
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2
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3
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4
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Cerner
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CPRS
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CPSI
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EPIC
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HMS
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Meditech
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Other:
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Rating Stars
(Click)
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SCOPE OF PRACTICE -
EXTRACORPOREAL SUPPORT
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1
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2
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3
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4
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Cardiopulmonary bypass for
Adult, Pediatric, and Neonatal Patients
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Cardiopulmonary bypass for
congenital and acquired cardiovascular disorders
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Extracorporeal circulatory
support for renal, neurological, hepatic and vascular surgery
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Extracorporeal
resuscitation
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Extracorporeal circulation
for long term support of failing respiratory and/or cardiac function
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ECMO Coverage Experience
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Rating Stars
(Click)
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ASSOCIATED EXTRACORPOREAL
SUPPORT FUNCTIONS
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1
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2
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3
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4
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Myocardial protection
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Hemofiltration/hemodialysis
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Anticoagulation and
hemostasis monitoring, analysis, and intervention
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Thermal regulation
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Blood gas and blood
chemistry monitoring, analysis, and intervention
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Physiological monitoring,
analysis, and intervention
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Administration of blood
components, pharmaceuticals, and anesthetic agents
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Rating Stars
(Click)
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HEART FAILURE THERAPY AND
SUPPORT
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1
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2
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3
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4
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Ventricular Assist Device
management
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Intra-aortic Balloon
Counterpulsation
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Temporary Pacemaker
management
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External counterpulsation
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Transportation of
Extracorporeal-Supported Patients
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Hemofiltration (i.e.
Aquapheresis)
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Periodic flow augmentation
therapy
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Rating Stars
(Click)
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BLOOD MANAGEMENT
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1
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2
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3
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4
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Autotransfusion
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Platelet Gel Production
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Non-Differentiated
Progenitor Cell HarvesT
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Acute Normovolemic
Hemodilution
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Phlebotomy
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Hemostasis monitoring and
analysis
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Rating Stars
(Click)
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OTHER CLINICAL
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1
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2
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3
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4
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Isolated limb/organ
perfusion
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Isolated limb/Organ
delivery of chemotherapeutics, progenitor cells, gene therapy vectors, etc.
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Organ Procurement
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Thermogenic Lavage
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Organ Preservation
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Dialysis
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Surgical assistance
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Electrophysiological
analysis
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Therapeutic Hyperthermia
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Therapeutic Hypothermia
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Intravascular membrane
oxygenation
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Rating Stars
(Click)
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NON-CLINICAL
RESPONSIBILITIES
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1
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2
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3
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4
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Documentation of duties via
the official medical record
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Education, including the
establishment and management of educational programs for new and current
clinical perfusionists, other healthcare providers, and consumers
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Administration, including
managing all aspects - technical, fiscal, workflow, and human resources of
Clinical Perfusion operations
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Quality Control and
Assurance
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Regulatory Compliance
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Rating Stars
(Click)
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EMR
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1
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2
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3
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4
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Epic
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Cerner
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Eclipsys
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McKesson
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Meditech
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Other Computerized System
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Computerized Physician
Order Entry
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Bar Coding for Medication
Administration
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MY EXPERIENCE IS
PRIMARILY IN:
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Unit
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No. of Years
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Unit
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No. of Years
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BURN
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POST PARTUM
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CRITICAL UNIT
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LABOR & DELIVERY
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PACU
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NEWBORN NURSERY
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NEUROLOGY
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LEVEL II NICU
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TELEMETRY
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LEVEL III NICU
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MEDICAL
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PICU
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SURGICAL
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PEDIATRICS
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ONCOLOGY
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OB/GYN
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ORTHOPEDICS
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PSYCHIATRY
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OPERATING ROOM
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RRT
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EMERGENCY ROOM
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CRT
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TRAUMA CENTER
LEVEL 1
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COMMUNITY ER
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RURAL ER
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Rating Stars
(Click)
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Age Specific Competencies
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1
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Newborn/Neonatal (birth –
30 days)
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Infant (30 days-1 year)
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Toddler (1-3 years)
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Preschool (3-5 years)
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School Age Children (5-12
years)
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Adolescent (12-17 years)
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Young Adults (18-44 years)
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Middle Adults (45-64 years)
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Older Adults (>65 years)
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