Your name
Your Email
Last 4 Of SSN
Date
E-Signature
I hereby certify that ALL information I have provided 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.
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Procedures
Assist with EGD’s: 0★★★★−
Assist with endoscopic ultrasound: 0★★★★−
Assist with active GI bleed: 0★★★★−
Cautery devices: 0★★★★−
Assist with manometry studies: 0★★★★−
Assist with variceal banding: 0★★★★−
Assist with esophageal dilatations: 0★★★★−
Assist with esophageal ballooning: 0★★★★−
Assist with scelrotherapy: 0★★★★−
Assist with TEE: 0★★★★−
Assist with bronchoscopy: 0★★★★−
Assist with colonoscopy: 0★★★★−
Assist with polypectomy: 0★★★★−
Assist with ERCP’s: 0★★★★−
Assist with PEG placements: 0★★★★−
Assist with liver BX: 0★★★★−
Assist with collection of hot & cold BX’s: 0★★★★−
Specimen collection & labeling: 0★★★★−
Set up of scopes & video equipment: 0★★★★−
Apply external abdominal pressure to assist with scope movement: 0★★★★−
Scope cleaning: 0★★★★−
Assist with mobile cases, ICU, ER, etc.: 0★★★★−
Radiation safety: 0★★★★−
Automated Medication Dispensing System, Pyxis, Omnicell, or other: 0★★★★−
Takes call for emergency cases: 0★★★★−
National Patient Safety Goals
Awareness of HCAHPS: 0★★★★−
Accurate patient identification: 0★★★★−
Effective communication: 0★★★★−
Interpretation & communication of lab values: 0★★★★−
Medication administration: 0★★★★−
Anticoagulation therapy: 0★★★★−
Monitoring conscious sedation: 0★★★★−
Pain assessment & management: 0★★★★−
Infection control: 0★★★★−
Universal precautions: 0★★★★−
Isolation: 0★★★★−
Minimize risk for falls: 0★★★★−
Prevention of pressure ulcers: 0★★★★−
Use of rapid response teams: 0★★★★−
Administer Conscious Sedation: 0★★★★−
Fentanyl: 0★★★★−
Propofol: 0★★★★−
Demerol: 0★★★★−
Presedex: 0★★★★−
Versed: 0★★★★−
Reversal agents: 0★★★★−
Pre Procedure
Pre procedure phone calls: 0★★★★−
Electronic documentation: 0★★★★−
Patient assessment: 0★★★★−
Colon prep or re-prep: 0★★★★−
Pre procedure checklist/consent: 0★★★★−
IV start, med admin: 0★★★★−
Post Procedure
Assess for air movement post colonoscopy: 0★★★★−
Assess for pain: 0★★★★−
Assess for bowel sounds: 0★★★★−
Assess for gag reflex post EGD: 0★★★★−
Assess for gag reflex post bronchoscopy: 0★★★★−
Recover from MAC: 0★★★★−
Recover from (moderate) conscious sedation: 0★★★★−
Discharge outpatients to home: 0★★★★−
Post procedure phone calls: 0★★★★−
Age Specific Competencies
Newborn/neonate (birth-30 days): 0★★★★−
Infant (31 days-1 year): 0★★★★−
Toddler (ages 2-3 years): 0★★★★−
Preschool (ages 4-5 years): 0★★★★−
School age (ages 6-12 years): 0★★★★−
Adolescent (ages 13-21 years): 0★★★★−
Young adult (ages 22-39 years): 0★★★★−
Adult (ages 40-64 years): 0★★★★−
Older adult (ages 65-79 years): 0★★★★−
Elderly (ages 80+ years): 0★★★★−
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