CYNET_SYSTEMS_MAIN_LOGO.gif   RESPIRATORY THERAPIST 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) General Skills 1 2 3 4  
Care of Patient in Restraints  
Electronic Documentation  
Isolation Precautions  
Medicare Documentation  
Patient/Family Education  
Written Documentation  
Rating Stars (Click) Care of Patients With 1 2 3 4  
Acute/Chronic Bronchitis  
ARDS  
Aspiration Pneumonia  
Asthma  
Atelectasis  
Bacterial/Viral Pneumonia  
Bronchiectasis  
Broncho-Pulmonary Dysplasia  
Cardiac Surgery  
Congestive Heart Failure  
Croup  
Cystic Fibrosis  
Diabetic Ketoacidosis  
Emphysema  
Epiglottitis  
Failure to Thrive  
Fem-pop Bypass  
Gullian Barre  
Hayaline Membrane Disease (HMD/IRDS)  
Lung Cancer  
Meconium Aspiration  
Myasthenia Gravis  
Myesthena Gravis  
Myocardial Infarction  
Near Drowning  
Neonatal Pneumonia  
Open Hearts  
Pacemakers  
Persistant Fetal Circulation  
Pulmonary Interstitial Emphysema (PIE)  
Pleural Effusion  
Pulmonary Edema  
Pulmonary Embolism  
Respiratory Failure  
Respiratory Syncytial Virus  
Respiratory Distress Syndrome  
Respiratory Distress Syndrome  
Tracheo-Esophageal Fistula  
Transient Tachpnea  
Thoracotomies  
Tuberculosis  
Rating Stars (Click) Therapy and Procedures 1 2 3 4  
Apnea Monitor  
Assessment of Breath Sounds  
Carbogen Delivery  
Diaphragmatic Breathing  
Disinfection and Sterilization  
End-Tidal CO2 Monitoring  
Nasal-Oral Airway Placement  
Oximetry  
Pursed Lip Breathing  
Transcutaneous Monitoring  
Rating Stars (Click) Oxygen Administration 1 2 3 4  
Acapella  
Aerosol Set Up/Mask/Trach  
Analyze Oxygen  
BiPAP Nasal/Mask  
Bronchial Hygiene Therapy  
Chest Physical Therapy/Postural Drainage  
CPAP Nasal/Mask  
Continuous Medication Nebulizer  
Cough Assisted machine  
Croup Tent Set Up  
EzPAP Expansion Therapy  
Flutter Valve Therapy  
Hand Held Nebulizer  
Heated Aerosol Mask/Trach Collar  
Heliox Delivery  
Incentive Spirometry (IS)  
Infant Hood Set Up  
Intrapulmonary Percussive Ventilation (IPV)  
Metered Dose Inhaler  
Nasal Cannula  
Nitric Oxide Delivery  
Oxgen Tank Set Up/Change Tank  
Partial Rebreather/Non-Rebreather Mask  
PEP Mask/PEP Valve Therapy  
Positive Pressure Breathing (IPPB)  
Simple Mask  
Splint Cough  
Sputum Induction  
Venturi Mask  
Vest Airway Clearance  
Rating Stars (Click) Obtaining Arterial Blood Gases 1 2 3 4  
ABG Interpretation/Analyzer  
Airway Pressure Release Ventilation (ARPV)  
Allen Test  
Arterial Blood Gas Analysis  
Arterial Line Insertion  
Arterial Line Maintenance  
Bronchoscopies/Assist  
Change, Clean Trach Tubes  
Check Intracuff Pressures  
Continuous Positive Airway Pressure (CPAP)  
Endotracheal  
Extubations  
Perform Independently  
Assist Only  
Femoral Artery  
Flow/Volume/Pressure Waveform Interpretation  
High Frequency Ventilator  
Independent Sychronous Lung Ventilation  
Inhaler Reservoirs  
Intra Aortic Balloon Pump (IABP)  
Intubations  
Perform Independently  
Assist Only  
Inverse Ratio Ventilation  
Nasotracheal  
Negative Inspiratory Force  
Peak Flow Rat Monitoring  
Positive End Expiratory Pressure (PEEP)  
Pressure Assist/Control  
Pressure Regulated Volume Control (PRVC)  
Pressure Support Ventilation (PSV)  
Pulmonary Function Testing  
Pulmonary Stress Testing  
Radial/Brachial Artery  
Rating Stars (Click) Ventilator Management 1 2 3 4  
Intermittent Mandatory Ventilation (IMV)  
Inverse Ratio Ventilation  
Pressure Release Modes/Techniques  
Suctioning  
Synchronized Intermittent Mandatory Ventilation (SIMV)  
Ventilate Patient with Manual Resuscitator  
Ventilator Modes  
Ventilator Set Up/On Tanks  
Volume Assist/Control  
Other:  
Rating Stars (Click) Settings  1 2 3 4  
Acute Care  
Adult Critical Care Unit  
Burn ICU  
Emergency Room  
Home Care  
Medical/Surgical General Floor Care  
Neonatal ICU Level II  
Neonatal ICU Level III  
Pediatric General Floor Care  
Pediatric ICU  
Pediatric ICU Level II  
Pediatric ICU Level III  
Pulmonary Rehabilitation  
Pulmonary Function Lab  
Skilled Nursing  
Sleep Lab  
Transplant  
Transports  
Rating Stars (Click) Equipment 1 2 3 4  
Bird/Avea  
Drager  
Puritan-Bennett  
Sechrist-Infant Star  
Servo  
Siemens  
SIMS  
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 1 2 3 4  
Newborn (birth – 30 days)  
Infant (30 days – 1 year)  
Toddler (1 – 3 years)  
Preschooler (3 – 5 years)  
School Age (5 – 12 years)  
Adolescents (12 – 18 years)  
Young Adults (18 – 39 years)  
Middle Adults (39 – 64 years)  
Older Adults (64+ years)