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REGISTERED NURSE CATH LAB
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)
WORK SETTING
1
2
3
4
Procedural Cath Lab
lnterventional Cath Lab
EP Lab
Interventional Radiology
Pre/Post Procedural Setting
Charge Experience
Other Setting (List)
Rating Stars (Click)
EQUIPMENT
1
2
3
4
Automatic Implantable Cardiac Defibrillator
Cardioversion
Cardioversion
Intra Aortic Balloon Pump (IABP)
SV02 Recording
Ventilator Management
Rating Stars (Click)
CARDIAC CATH LAB PROCEDURES
1
2
3
4
AICD Placement
Aortography
Cardiac Biopsy
Cardiac Implant Closure Device
Cardiac Stent Placement
Diagnostic Cardiac Catheterization Adult
Diagnostic Cardiac Catheterization-Pediatric/Neonatal
Directional Coronary Atherectomy
IABP Placement/Removal
Internal Mammary Angiography
Laser Assisted Procedures
Percutaneous Transluminal Coronary Angioplasty
Pericardiocentesis
Permanent Pacemaker Placement
Pulmonary Angiography
Rotational Coronary Atherectomy
Saphenous Vein Graft Angiography
Transluminal Extraction Catheter
Valvuloplasty
Ventricular Assist Device Insertion
Rating Stars (Click)
ELECTROPHYSIOLOGY PROCEDURES
1
2
3
4
Electrophysiology Evaluation
Baseline Measurements
Cardiac Ablation
Cardiac Mapping
Cardioversion
Conduction Study
Internal Cardioverter Defibrillator Implant
Tilt Table Study
Rating Stars (Click)
IR-GASTROINTESTINAL STUDIES
1
2
3
4
Angioplasty
Chemoembolization
Cholecystostomy
Embolization
ERCP
Esophageal Stent Placement
Gastrojejunostomy
Gastrostomy Tube Placement
Liver Ablation
Pericentesis
Percutaneous Hepatic Angiography
TIPS
Rating Stars (Click)
IR-GENITOURINARY STUDIES
1
2
3
4
Adrenal Angiography
Angiography of Female GU System
Angiography of Male GU System
Cystostomy
Embolization
Nephrostomy
Percutaneous Stone Extraction
Renal Angiography
Renal Artery Angioplasty
Renal Artery Stent Placement
Ureteral Stent
Rating Stars (Click)
IR-NEUROLOGIC STUDIES
Cerebral Angiography
Carotid Angiography
Neurologic Angioplasty
Neurologic Thrombolysis
Vertebroplasty
Rating Stars (Click)
IR-PERIPHERAL VASCULAR STUDIES
IR-PERIPHERAL VASCULAR STUDIES
Angioplasty
Central Venous Access/Port Placement
Dialysis Graft Creation/Revision
Dialysis Graft lnterventional
Peripheral Vascular Embolization
Stent Graft Placement
SVC/IVC Venograph
Thoracic Aortography
Upper and Lower Extremity Angiography
Rating Stars (Click)
IR-PULMONARY PROCEDURES
Chest Tube Placement
Pulmonary Embolization
Pulmonary Angiography
Thoracentesis
Rating Stars (Click)
PROFESSIONAL KNOWLEDGE AND SKILLS
Conscious/Procedural Sedation
Assist w/Central Line/Venous Line Insertion
Venous Sampling
Topical Hemostasis (D-Stat, Chito-Seal, Syvek Patch, etc.)
Vascular Closure Systems (Perclose, StarClose, etc.)
External Compression Devices (C-Clamp, Sandbags,etc.)
Physiologic Monitoring/Recording
Sheath Removal and Monitoring
National Patient Safety Goals/Core Measures
Universal Protocol Procedures
Isolation Precautions
Infection Prevention
Age Specific/Population-Based Care
Fall Risk Assessment/Prevention
Rating Stars (Click)
EMR
Cerner
Eclipsys
Epic
GE
McKesson
Meditech
Other Computerized System
Computerized Physician Order Entry
Medication Administration using Bar Co
ding Technology
EMR Conversion
YES
NO
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)
CERTIFICATIONS
Expiry Date :
BLS
ACLS
PALS
CCRN
Telemetry Certificate
Arrhythmia Course
Other: Specify
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