Interventional Radiology RN Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) This field is hidden when viewing the formDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyGENERALAdmit patient to pre-procedure holding(Required) 1 2 3 4 Complete assessments, obtain family history & risk factors(Required) 1 2 3 4 Start peripheral IV(Required) 1 2 3 4 Complete pre-procedure checklist(Required) 1 2 3 4 Transport pre-procedure patient to the Lab.(Required) 1 2 3 4 Transport post-procedure patient to in-hospital units(Required) 1 2 3 4 PROCEDURESCerebral Angiogram – Prepare(Required) 1 2 3 4 Cerebral Angiogram – Assist(Required) 1 2 3 4 Lower Extremity Angiogram – Prepare(Required) 1 2 3 4 Lower Extremity Angiogram – Assist(Required) 1 2 3 4 Upper Extremity Angiogram – Prepare(Required) 1 2 3 4 Upper Extremity Angiogram – Assist(Required) 1 2 3 4 Ultrasound Guided Biopsy – Prepare(Required) 1 2 3 4 Ultrasound Guided Biopsy – Assist(Required) 1 2 3 4 CT Scan Guided Biopsy – Prepare(Required) 1 2 3 4 CT Scan Guided Biopsy – Assist(Required) 1 2 3 4 Liver Biopsy and Embolization – Prepare(Required) 1 2 3 4 Liver Biopsy and Embolization – Assist(Required) 1 2 3 4 Prepare and Assist with Line Placement – Broviac(Required) 1 2 3 4 Prepare and Assist with Line Placement – Groshong(Required) 1 2 3 4 Prepare and Assist with Line Placement – Hickman(Required) 1 2 3 4 Prepare and Assist with Line Placement – PICC(Required) 1 2 3 4 Prepare and Assist with Line Placement – PortaCath(Required) 1 2 3 4 Uterine Fibroid Embolization – Prepare(Required) 1 2 3 4 Uterine Fibroid Embolization – Assist(Required) 1 2 3 4 Temporary Hemodialysis Shunt Placement– Prepare(Required) 1 2 3 4 Temporary Hemodialysis Shunt Placement– Assist(Required) 1 2 3 4 Permanent Hemodialysis Shunt Placement– Prepare(Required) 1 2 3 4 Permanent Hemodialysis Shunt Placement– Assist(Required) 1 2 3 4 AV Fistula/Shunt Declotting – Prepare(Required) 1 2 3 4 AV Fistula/Shunt Declotting – Assist(Required) 1 2 3 4 Vertebroplasty – Prepare(Required) 1 2 3 4 Vertebroplasty – Assist(Required) 1 2 3 4 Lumbar Puncture – Prepare(Required) 1 2 3 4 Lumbar Puncture – Assist(Required) 1 2 3 4 Myelogram – Prepare(Required) 1 2 3 4 Myelogram – Assist(Required) 1 2 3 4 Other Procedures (please list):(Required) 1 2 3 4 Provide care for the post-procedure patient(Required) 1 2 3 4 CARDIOVASCULARAssess heart sounds and peripheral pulses(Required) 1 2 3 4 Interpret arrhythmias(Required) 1 2 3 4 Perform CPR(Required) 1 2 3 4 Perform defibrillation(Required) 1 2 3 4 Participate as a team member in resuscitation(Required) 1 2 3 4 PULMONARYAssess lung sounds(Required) 1 2 3 4 Set up oxygen devices(Required) 1 2 3 4 Obtain pulse oximetry reading(Required) 1 2 3 4 Interpret ABG(Required) 1 2 3 4 Use Ambu bag(Required) 1 2 3 4 Assist with intubation(Required) 1 2 3 4 Assist with chest tube insertion(Required) 1 2 3 4 Provide care for the patient with mechanical ventilation(Required) 1 2 3 4 MEDICATIONSTitrate vasoactive drugs(Required) 1 2 3 4 Calculate mcg/min and mcg/kg/min(Required) 1 2 3 4 Use IV infusion pump to calculate drug doses(Required) 1 2 3 4 Administer IV nitroglycerine(Required) 1 2 3 4 Administer IV dobutamine (Dobutrex)(Required) 1 2 3 4 Administer IV lidocaine(Required) 1 2 3 4 Administer IV diltiazem (Cardizem)(Required) 1 2 3 4 Administer IV epinephrine(Required) 1 2 3 4 Administer IV atropine(Required) 1 2 3 4 Administer IV heparin(Required) 1 2 3 4 Administer IV benzodiazepines (Valium, Versed, Ativan)(Required) 1 2 3 4 Administer IV propofol (Diprivan)(Required) 1 2 3 4 Administer IV neuromuscular blocking agents (Pavulon, Norcuron)(Required) 1 2 3 4 Administer IV narcotics (morphine, fentanyl)(Required) 1 2 3 4 PAIN/WOUND MANAGEMENTAssess pain level/tolerance(Required) 1 2 3 4 Care of patient with anesthesia/analgesia(Required) 1 2 3 4 Care of patient with IV conscious sedation(Required) 1 2 3 4 Care of patient with narcotic analgesia(Required) 1 2 3 4 Care of patient with patient controlled analgesia (PCA pump)(Required) 1 2 3 4 Assess surgical wound status with/without drain(s)(Required) 1 2 3 4 Care of patient with sterile dressing changes(Required) 1 2 3 4 Assessment of VasoSeal, AngioSeal, PerClose success(Required) 1 2 3 4 AGE SPECIFIC PRACTICE CRITERIAPediatric (1-18years)(Required) 1 2 3 4 Adolescents (12 - 18 years)(Required) 1 2 3 4 Adult (19 - 65 years)(Required) 1 2 3 4 Older adults (Older than 65years)(Required) 1 2 3 4 EXPERIENCE WITH AGE GROUPSCalculate body weight to verify correct dosing of medication(Required) 1 2 3 4 Assess immunization status for pediatric, and adolescent(Required) 1 2 3 4 Set age-appropriate short-term and long-term goals in care planning(Required) 1 2 3 4 Provide age-appropriate education, considering possible vision and hearing impairment for Older than 65years(Required) 1 2 3 4 CERTIFICATIONSACLS(Required) Yes No ACLS Expiry Date :MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920BCLS(Required) Yes No BCLS Expiry Date :MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Other: SpecifyOther Expiry Date :MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. 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