Proﬁciency Scale:

0 = No Experience/Observed Only

1 = Limited Experience/Rarely Done (6 times/year)

2 = May Need Some Review/Occasionally Done (1 - 2 times/month)

3 = Experienced/Frequently Done (daily or weekly)

GENERAL SKILLS

0

1

2

3

Care of Patient in Restraints

Access/Management of Implanted Ports

Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)

Titration of drips

Administration of Blood/Blood Products

Leading Code Teams

Use of Computerized Patient ID Systems

Knowledge of Current IV Therapy Guidelines (INS, ISMP, CDC, State, Etc.)

Knowledge of Anatomy

Moderate Conscious Sedation

Sedation Reversal Agents

Knowledge of "Do Not Use Abbreviations"

Do you have charge/supervisor experience?

Knowledge of current Joint Commission National Patient Safety Goals

Knowledge/familiarity with HCAHPS scores

MIDLINE'S/PICC LINES:

0

1

2

3

Midline Catheter Insertion - Adult

Midline Catheter Insertion - Child

Indications for Midline/PICC Placement

Contraindications for Midline/PICC Placement

Vein Selection

Measuring Techniques

Catheter and Introducer Device Selection

Correct Tip Placement

Insertion Technique - Basic (Vein)

Insertion Technique - Seldinger

Insertion Technique - Ultrasound

Assist with Insertion in Interventional Radiology

Insertion Site Preparation

Maintaining Sterile Field

Securing Insertion Site Post Placement

X-ray Assessment for Tip Location

Repositioning After X-ray

MEDICATION ADMINISTRATION

0

1

2

3

Chemotherapy

Heparin

Streptokinase

TPA (Alteplase)

Lidocaine

TPN/Lipids

Ativan (Lorazepam)

Valium (Diazepam)

Versed (Midazolam)

Fentanyl

TROUBLESHOOTING/ COMPLICATIONS:

0

1

2

3

Repair PICC

Repair Midline

Air Embolism

Bleeding

Brachial Plexus Injury

Cardiac Arrhythmia

Cardiac Tamponade

Catheter Erosion

Catheter Embolism

Catheter Occlusion

Catheter-Related Sepsis

Endocarditis

Exit Site Infection

Exit Site Necrosis

Extravasation

Hematoma

Laceration of Vessels or Viscus

Myocardial Erosion

Perforation of Vessels or Viscus

Phlebitis

Catheter Tip Malposition or Retraction

Thromboembolism

Venous Thrombosis

Ventricular Thrombosis

Vessel Erosion

Declotting Peripheral Site

Complications from Sedation

GENERAL SKILLS - Automated Med Dispensing Systems (check all that apply)

Accudose Metro Omnicell Promanager Rx Pyxis N/A

IV Pumps (check all that apply):

Alaris Alibaba Bard Baxter Braun CADD IVAC Zynomed N/A

Please list any additional areas of expertise below:

I certify that all the above information is correct, and that any misrepresentation or falsification of fact may be considered sufficient cause for immediate dismissal from the agency. I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.

Personal Information

Proﬁciency Scale:

IV THERAPY EXPERIENCE WITH THE FOLLOWING AGES:

GENERAL SKILLS

INSERTION OF:

MIDLINE'S/PICC LINES:

CARE AND MAINTENANCE:

MEDICATION ADMINISTRATION

EQUIPMENT:

TROUBLESHOOTING/ COMPLICATIONS:

DISCONTINUING IV THERAPY

GENERAL SKILLS - Automated Med Dispensing Systems (check all that apply)

GENERAL SKILLS - Electronic Documentation (check all that apply)

IV Pumps (check all that apply):