CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE DIALYSIS 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) WORK SETTINGS 1 2 3 4  
Acute/Inpatient Dialysis   
Chronic/Outpatient Dialysis   
Dialysis Home Care   
Pediatric Dialysis   
Apheresis   
Plasmapheresis   
Predialysis Nursing Assessment   
Charge Experience  
Rating Stars (Click) SET UP/INITIATE DIALYSIS TREATMENT 1 2 3 4  
Bicarbonate Dialysate   
Conductivity Testing  
Priming Dialyzer   
Prep Vascular Access   
Fistula Gortex/Bovine Graft   
Anticoagulation Management   
Apheresis   
Plasmapheresis   
Cannulating Buttonholes   
Continuous Renal Replacement Therapy   
Peritoneal Dialysis  
Rating Stars (Click) ASSESSMENT DURING DIALYSIS 1 2 3 4  
Vascular Access Function  
Arterial and Venous Pressures   
Blood Flow Rate  
Management of Anticoagulation   
Conductivity   
Ultra Filtration Calculation   
Operation of Myron L. Meter   
Administration of Blood and Blood Products   
Administration of Mannitol   
Sequential Ultrafiltration/PUF  
Rating Stars (Click) PATIENT MANAGEMENT 1 2 3 4  
Fluid Overload   
Hypertension   
Hypotension   
Disequilibrium Syndrome   
Hyperkalemia   
Seizures   
Muscle Cramps  
Clotted Access/Poor Blood Flow Rate from Catheter   
Pyrogenic Reaction   
Hemolysis   
Air Embolus   
Chest Pain   
Anemia   
Neuropathy   
Pericarditis   
Filter Blood Leak   
Cardiopulmonary Arrest   
Anticoagulation Emergencies  
Rating Stars (Click) DIALYSIS EQUIPMENT 1 2 3 4  
Baxter   
Cobe   
Fresenius H/K   
Gambro   
Phoenix   
T Machine   
Other    
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS 1 2 3 4  
National Patient Safety Goals   
Patient Isolation/Infection Prevention   
Management of Dialysis Equipment Alarms   
Bedside Blood Glucose Monitoring   
Pyxis Medication Admin. System   
Computerized Charting   
Proton Charting Experience   
AMI Charting Experience   
Ecube Charting Experience  
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  
Infant (Birth - 1 year)  
Preschooler (ages 2-5 years)  
Childhood (ages 6-12 years)  
Adolescents (ages 13-21 years)  
Young Adults (ages 22-39 years)  
Adults (ages 40-64 years)  
Older Adults (ages 65-79 years)  
Elderly (ages 80+ years)  
Elderly (ages 80+ years)