EP Skills Checklist

EP Skills Checklist

First Name*

Last Name*

Years of Experience*

E-mail*

example@example.com

ANSWER KEY

PROFICIENCY

1=Not Applicable 2=No Experience 3=Some Experience

4=Experienced 5=Very Experienced

FREQUENCY

1=Never Performed 2=Assisted Only 3=Rarely Performed

4=Occasionally Performed 5=Regularly Performed

General Skills*

	Proficiency	Frequency
Standard Precautions
Isolation Precautions
Pediatric Respiratory / Cardiac Arrest
Adult Respiratory / Cardiac Arrest
Crash Carts
Defibrillators
Care of Patient in Restraints
Pain Management
Automated Med Dispensing Systems
Care Planning & Discharge Planning
Patient / Family Education
Electronic Documentation
Patient Head to Toe Assessment
Peripheral IV Insertion, Care, and Maintenance
Pediatric Ventilator Management
Adult Ventilator Management
Sterile Field
Pulse Oximetry
Use of Portable Monitors
Cardiac Monitoring
EKG Interpretation (Basic)
EKG Interpretation (Advanced)
Airway Management
Oxygen Delivery Devices
Care of the Patient Under Neutropenic or Bleeding Precautions
End of Life Care

Medications*

	Proficiency	Frequency
Calculate Mcg / Min and Mcg / Kg / Min
Titrating Medications
Isuprel
Procainamide
Esmolol
Adenosine
Amiodarone
Antibiotics
Analgesics
Sedatives

Assessment & Monitoring*

	Proficiency	Frequency
Lead Placement
Basic 12 Lead EKG Interpretation
Cardiac Rhythm Interpretation
Doppler
Blood Pressure Invasive and Non-Invasive

Hemodynamic Monitoring*

	Proficiency	Frequency
Art Line
Swan Ganz
Waveform Assessment
General Lab Work Interpretation
ABG Interpretation
Cardiac Enzyme Interpretation
Chemistry Interpretation

Care and Maintenance*

	Proficiency	Frequency
Central Venous Access Device
Arterial Line
Swan Ganz
IABP
SHEATHS
Removal of Sheath
Manual Pressure Hold
C-Clamp
FemoStop
VasoSeal, Angioseal, Perclose
Hematoma Recognition / Management

Procedure Equipment*

	Proficiency	Frequency
Scrub EP Procedures
Circulate EP Procedures
Ablation (Atrial / Ventricular)
Carto Mapping
Bloom Stimulator
Diagnostic Catheters-BI-V
Stereotaxis
AICD Placement
PPM
Temporary Pacemaker
Cardioversion
Internal Cardioversion Catheters
NIPS Procedure
Pericardiocentesis
Demonstrate Proper Preservations of Tissue Specimen for Lead Extractions
ACT Machine
Device Implants

Age Specific Criteria*

	Proficiency	Frequency
Newborn / Neonatal (up to 30 days)
Infant (30 days to 1 year)
Toddler (1 to 3 years)
Preschooler (3 to 5 years)
School Age (5 to 12 years)
Adolescents (12 to 18 years)
Young Adults (18 to 39 years)
Middle Adults (40 to 64 years)
Older Adults (65 & up)

Background Experience*

	Proficiency	Frequency
Small Hospital
Large Hospital
Outpatient
Acute Care / Hospital
Cancer Center
Clinic
Managed Care
SNF/ Long Term Care
Home Health

The information provided is true and to the best of my knowledge. I hereby authorize Summit Medical Staffing to present my Skills Checklist to facilities for the purpose of employment. Please Type Your Name in This Box to Electronically Sign this Form.*

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Date*

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