CYNET_SYSTEMS_MAIN_LOGO.gif   RADIOLOGY TECHNOLOGIST
ANNUAL CLINICAL COMPETENCY AND 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) SETTING 1 2 3 4  
Adult Inpatient   
ER/Trauma   
Adult Outpatient  
Pediatric Inpatient  
Pediatric Outpatient  
Rating Stars (Click) Procedures  1 2 3 4  
Chest Studies   
Abdominal Studies   
Foreign Body/Soft Tissue Studies   
Specimen Radiography   
Rating Stars (Click) Extremities  1 2 3 4  
Upper   
Lower  
Pelvis Obls/Judet Views   
Pelvis SI Joints   
Pelvis Sacrum/Coccyx   
Rating Stars (Click) Spine  1 2 3 4  
Cervical Spine-Obls/Flexion/Extension   
Thoracic Spine-Swimmer’s View   
Lumbar Spine-Obls/Flexion. Extension   
Rating Stars (Click) Head  1 2 3 4  
Facial Bones   
Mandible   
Rating Stars (Click) Head (cont.)  1 2 3 4  
Mastoids   
Orbits   
Sinus Series   
TMJ   
Skull Series   
Rating Stars (Click) Tomography 1 2 3 4  
Renal  
TMJ  
Spine   
Rating Stars (Click) Flouroscopy/Contrast Studies  1 2 3 4  
Barium Swallow/Esophagram   
Modified Barium Swallow/Protocol Swallow   
Swallow Studies with Videotaping  
Upper GI Series-Single Contrast   
Upper GI Series-Air Contrast  
Small Bowel Follow Through   
Rating Stars (Click) Enema Studies  1 2 3 4  
Barium Enema-Single Contrast  
Water Soluble Contrast Enema (e.g. Hypaque)   
 Barium Enema-Air Contrast  
Lower GI Studies thru Colostomy   
Rating Stars (Click) Cystography  1 2 3 4  
Cystogram  
Voiding Cystogram   
Rating Stars (Click) Cystography (cont.) 1 2 3 4  
Urethrography   
Rating Stars (Click) Contrast Injection Studies  1 2 3 4  
IVP   
IVP with Tomograms   
Rating Stars (Click) Myelograms 1 2 3 4  
Cervical Spine  
Thoracic Spine   
Lumbar Spine   
Rating Stars (Click) Mobile C-Arm Flouroscopy 1 2 3 4  
Broncoscopy with Fluoro Guidance   
Bedside Line and Tube Placement   
Rating Stars (Click) OR Cases 1 2 3 4  
Sterile Procedures in OR  
Spine Work  
Operative Cholangiography  
Hip Studies  
Extremity Studies   
 Cystography   
Retrograde Urography   
Rating Stars (Click) Patient Safety 1 2 3 4  
National Patient Safety Goals   
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)