Infusion Skills Checklist

Infusion 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*

	Proficiency	Frequency
Verify Patient Allergies
Provide the Patient with Education and Handbook
Verify Physician Order
Explain Procedure to Patient
Educate Clinical Staff on Care of Vascular Access Devices
Verify Patient Contraindications to Vascular Access Placement
Obtain Signed Consent
Verify Patient Labs and Medical History
Document Procedure Performed in Patient Record
Electronic Medical Records
Verify Patient Coagulation Status
Explain Catheter Management to Patient
Appropriate Site and Catheter Selection

Patient Management*

	Proficiency	Frequency
Diabetic
Infectious Diseases
Growth and development
Cognitive function
Fluid and Nutritional Status
Cardiovascular
Antepartum conditions
Central Nervous System
Postpartum Conditions
Hematologic
Respiratory
Disease states and conditions
Gastrointestinal
Neoplastic
Body surface area
Nutritional status

Technology and Clinical Applications*

	Proficiency	Frequency
PICC Insertion/Maintenance/Troubleshooting
Central Access Bundle
Short Peripheral Insertion/Maintenance/Troubleshooting
Nontunneled Catheter Maintenance/Troubleshooting
Implanted Device Maintenance/Troubleshooting
Tunneled Catheter Maintenance/Troubleshooting
Midline Insertion/Maintenance/Troubleshooting

Infusion Management*

	Proficiency	Frequency
Biologic Therapy
Cardiovascular Agents
Infusion Pumps
Alteplase (Cathflo) Use
Electrolyte Maintenance and Replacement
Antineoplastic Therapy
Gastrointestinal Agents
Respiratory Agents
Anti-infective Agents
CNS Agents
Parenteral Nutrition
Hormones and Synthetic Substitute Agents

Transfusion Therapy*

	Proficiency	Frequency
White blood cells (leukocytes)
Platelets
Red blood cells
Factor products
ABO-Rh
Rh immune globulin
Plasma/albumin

Setup*

	Proficiency	Frequency
Perform Skin Prep
Gathers Appropriate Equipment
Pre-Flush Catheter/Syringes/Extension Sets
Set Up Equipment and Sterile Field

Insertion*

	Proficiency	Frequency
Attach Hub
Modified Seldinger Technique
Ascertain Blood Return
Remove Introducer
Confirm Catheter Tip Position
Venipuncture
Remove Guide-wire
Re-Position if Needed
Advance Catheter
Suture or Utilize Securing Method

General*

	Proficiency	Frequency
Artery cannulation prevention & intervention
Prevention & Intervention for air embolus
Obtaining culture insertion site
Universal Precautions
CAVT (catheter- associated venous thrombosis) prevention & intervention
Infection Prevention and Control
Prevention & intervention for malpositioned catheters
Device Removal
Prevention & intervention for catheter embolus
Blood culture for potentially infected lines
Post Removal Instructions to Patient and/or Nursing Staff
Sterile Technique

Identify, Evaluate and Select*

	Proficiency	Frequency
Appropriate Vein
Correctly Measure Patient Properly for Catheter Tip Location
Position Patient Properly
Location of Artery
Appropriate Insertion Site
Choose Appropriate Catheter Length and Gauge Size

General*

	Proficiency	Frequency
0-30 days
30 days - 1 year
1 - 3 years
3 - 5 years
5 - 12 years
12 - 18 years
18 - 39 years
39 - 64 years
64+ years

Clinical Settings*

	Proficiency	Frequency
Acute Care
Home Health
Critical Care
Out Patient Clinics
Post Acute Care

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. *

First NameLast Name

Date*

MonthDayYear

Hour MinutesAM/PM Option

Form Reply Email Address

Salesforce Check

Assessment / Patient Care

Medications / Therapeutic Interventions

Procedures / Equipment

Age Group Experience