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Date
* Applicant's Name: Last
Middle Initial
* First
To ArdorHealthSolutions Healthcare Professionals:
The following checklist is a profile used to assess your clinical proficiency and assist in matching your skills with available assignments. Your employment is not dependent upon responses given in this checklist. Please rate your ability as accurately as possible by checking the appropriate box.
The information I have given here is true and accurate to the best of my knowledge. In addition, I also authorize ArdorHealthSolutions to release this skills checklist to client institutions of ArdorHealthSolutions in relation to my employment with that institution.
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* Date
Please Mark Your Level of Experience 1 - No Experience: Theory / Observed Only 2 - Intermittent Experience: < 5 Times Per Year; Needs Review 3 - Moderate Experience: > 5 Times Per Year; May Need Minimal Resource 4 - Competent: Performs on Daily or Weekly Basis; Proficient
Cardiovascular
1
2
3
4
Able to Perform:
Cardioversion
Defibrillation
Member of Code Team
Run Code
Titrate Drugs
Arrhythmia Interpret
Assist with Insertion and Set Up:
Arterial Line
Central Venous Catheter
Assist with Open Chest Procedure
Basic 12 Lead ECG Interpretation
Care of Heart Transplant Patient
Care of Open Heart Surgery Patient (24-48 Hour Post Op.)
Care of Patient with:
Angina
CHF
Femoral Popliteal Bypass
Care of Patient with Abdominal Aortic Aneurysm
Care of Patient with Acute Myocardial Infarction
Care of Patient with Pacemakers:
Permanent
Placement Of External Pacemaker
Transthoracic (Epicardial)
Transvenous
Emergency Medication Administration:
Atropine
Bicarbonate
Epinephrine
Management Of Patient On Drips:
Bretylium
Dopamine
Insulin
Lidocaine
Proselyte
Obtain Samples for:
Arterial Blood Gases
Mixed Venous Gases
Placement Of Patient On Cardiac Monitor
Prepare For PTCA
Neurological
Craniotomy
Acute CVA
Head Injury
Spinal Cord Injury
Cerebral Aneurysm
Seizures
Care of Patient with Halo Traction/Cervical Tongs
Care of Patient with Ventriculostomy
Epidural Medication Administration
Increased ICP Mgmt. (eg. Positioning/Temp. Regulation/Medications)
Perform Advanced Neuro Assessment (eg. Cranial Nerves/Reflexes/Visual or Communication Deficits)
Perform Basic Neuro Assessment/Neuro Vitals
Recognition And Intervention Of Complications (eg. CSF Leak/Clot/Herniation)
Use of Rotating Bed
Stryker Frame
Miscellaneous
Abdominal Surgery
AIDS
Burns
GI Bleed
Hemodialysis
Isolation
Multiple Trauma
New Colostomy
Organ And Tissue Donation
Peritoneal Dialysis
Renal Failure
Septic Shock
Pulmonary
Assist with Bronchoscopy
Assist with Intubation
Assist with Thoracen
Care of Intubated Patient (eg. Suctioning, ETT Care, Cuff Pressures)
ARDS
COPD
Pneumonia
Status Asthmaticus
Care of Patient with Chest Tube
Care of Patient with Pulmonary Edema
Care of Patient with Tracheostomy
Care of Ventilator Patient
Identify An Intervene Respiratory Complications s (eg. Tension Pneumothorax, Aspiration, Pulmonary Edema, Laryngospasm)
Interpret Arterial Blood Gases
Units Worked
Years
Burn
Cardiothoracic
Coronary Care
Medical
Surgical
Telemetry
Trauma
Courses
Yes
No
Exp Date
Have you taken an arrhythmia course?
Have you taken a formal critical care course?
Certifications
CCRN
ACLS
CNRN
Total number of years experience in Telemetry/Intermediate Care nursing:
