Cath Lab / Interventional Radiology Nursing Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWork SettingProcedural Cath Lab 1 2 3 4 lnterventional Cath Lab 1 2 3 4 EP Lab 1 2 3 4 Interventional Radiology 1 2 3 4 Pre/Post Procedural Setting 1 2 3 4 Charge Experience 1 2 3 4 Automatic Implantable Cardiac Defibrillator 1 2 3 4 Cardioversion 1 2 3 4 Intra Aortic Balloon Pump (IABP) 1 2 3 4 SV02 Recording 1 2 3 4 Ventilator Management 1 2 3 4 Other SettingsCardiac Cath Lab ProceduresAICD Placement 1 2 3 4 Aortography 1 2 3 4 Cardiac Biopsy 1 2 3 4 Cardiac Implant Closure Device 1 2 3 4 Cardiac Stent Placement 1 2 3 4 Diagnostic Cardiac Catheterization Adult 1 2 3 4 Diagnostic Cardiac Catheterization-Pediatric/Neonatal 1 2 3 4 Directional Coronary Atherectomy 1 2 3 4 IABP Placement/Removal 1 2 3 4 Internal Mammary Angiography 1 2 3 4 Laser Assisted Procedures 1 2 3 4 Percutaneous Transluminal CoronaryAngioplasty 1 2 3 4 Pericardiocentesis 1 2 3 4 Permanent Pacemaker Placement 1 2 3 4 Pulmonary Angiography 1 2 3 4 Rotational Coronary Atherectomy 1 2 3 4 Saphenous Vein Graft Angiography 1 2 3 4 Transluminal Extraction Catheter 1 2 3 4 Valvuloplasty 1 2 3 4 Ventricular Assist Device Insertion 1 2 3 4 Electrophysiology ProceduresElectrophysiology Evaluation 1 2 3 4 Baseline Measurements 1 2 3 4 Cardiac Ablation 1 2 3 4 Cardiac Mapping 1 2 3 4 Cardioversion 1 2 3 4 Conduction Study 1 2 3 4 Internal Cardioverter Defi brillator Implant 1 2 3 4 Tilt Table Study 1 2 3 4 IR-Gastrointestinal StudiesAngioplasty 1 2 3 4 Chemoembolization 1 2 3 4 Cholecystostomy 1 2 3 4 Embolization 1 2 3 4 ERCP 1 2 3 4 Esophageal Stent Placement 1 2 3 4 Gastrojejunostomy 1 2 3 4 Gastrostomy Tube Placement 1 2 3 4 Liver Ablation 1 2 3 4 Pericentesis 1 2 3 4 Percutaneous Hepatic Angiography 1 2 3 4 TIPS 1 2 3 4 IR-Genitourinary StudiesAdrenal Angiography 1 2 3 4 Angiography of Female GU System 1 2 3 4 Angiography of Male GU System 1 2 3 4 Cystostomy 1 2 3 4 Embolization 1 2 3 4 Nephrostomy 1 2 3 4 Percutaneous Stone Extraction 1 2 3 4 Renal Angiography 1 2 3 4 Renal Artery Angioplasty 1 2 3 4 Renal Artery Stent Placement 1 2 3 4 Ureteral Stent 1 2 3 4 IR-Neurologic StudiesCerebral Angiography 1 2 3 4 Carotid Angiography 1 2 3 4 Neurologic Angioplasty 1 2 3 4 Neurologic Thrombolysis 1 2 3 4 Vertebroplasty 1 2 3 4 IR-Peripheral Vascular StudiesIR-Peripheral Vascular Studies 1 2 3 4 Angioplasty 1 2 3 4 Central Venous Access/Port Placement 1 2 3 4 Dialysis Graft Creation/Revision 1 2 3 4 Dialysis Graft lnterventional 1 2 3 4 Peripheral Vascular Embolization 1 2 3 4 Stent Graft Placement 1 2 3 4 SVC/IVC Venograph 1 2 3 4 Thoracic Aortography 1 2 3 4 Upper and Lower Extremity Angiography 1 2 3 4 IR-Pulmonary ProceduresChest Tube Placement 1 2 3 4 Pulmonary Embolization 1 2 3 4 Pulmonary Angiography 1 2 3 4 Thoracentesis 1 2 3 4 Professional Knowledge and SkillsConscious/Procedural Sedation 1 2 3 4 Assist w/Central Line/Venous Line Insertion 1 2 3 4 Venous Sampling 1 2 3 4 Topical Hemostasis (D-Stat, Chito-Seal, SyvekPatch, etc.) 1 2 3 4 Vascular Closure Systems (Perclose, StarClose,etc.) 1 2 3 4 External Compression Devices (C-Clamp,Sandbags,etc.) 1 2 3 4 Physiologic Monitoring/Recording 1 2 3 4 Sheath Removal and Monitoring 1 2 3 4 National Patient Safety Goals/Core Measures 1 2 3 4 Universal Protocol Procedures 1 2 3 4 Isolation Precautions 1 2 3 4 Infection Prevention 1 2 3 4 Age Specific/Population-Based Care 1 2 3 4 Fall Risk Assessment/Prevention 1 2 3 4 EMRCerner 1 2 3 4 Eclipsys 1 2 3 4 Epic 1 2 3 4 GE 1 2 3 4 McKesson 1 2 3 4 Meditech 1 2 3 4 Other Computerized System 1 2 3 4 Computerized Physician Order Entry 1 2 3 4 Medication Administration using Bar Coding Technology 1 2 3 4 EMR Conversion Yes CertificationsBLS Yes BLS Expiration Date Month Day Year ACLS Yes ACLS Expiration Date Month Day Year PALS Yes PALS Expiration Date Month Day Year CCRN Yes CCRN Expiration Date Month Day Year Telemetry Certificate Yes Telemetry Certificate Expiration Date Month Day Year Arrhythmia Course Yes Arrhythmia Course Expiration Date Month Day Year Other: SpecifyOther Expiration Date Month Day Year Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Cath Lab / Interventional Radiology Nursing Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
