CYNET_SYSTEMS_MAIN_LOGO.gif   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 Coding Technology    
  EMR Conversion
   
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