Dialysis 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 SettingsAcute/Inpatient Dialysis 1 2 3 4 Chronic/Outpatient Dialysis 1 2 3 4 Dialysis Home Care 1 2 3 4 Pediatric Dialysis 1 2 3 4 Apheresis 1 2 3 4 Plasmapheresis 1 2 3 4 Predialysis Nursing Assessment 1 2 3 4 Charge Experience 1 2 3 4 Set Up/Initiate Dialysis TreatmentBicarbonate Dialysate 1 2 3 4 Conductivity Testing 1 2 3 4 Priming Dialyzer 1 2 3 4 Prep Vascular Access 1 2 3 4 Fistula Gortex/Bovine Graft 1 2 3 4 Anticoagulation Management 1 2 3 4 Apheresis 1 2 3 4 Plasmapheresis 1 2 3 4 Cannulating Buttonholes 1 2 3 4 Continuous Renal Replacement Therapy 1 2 3 4 Peritoneal Dialysis 1 2 3 4 Assessment During DialysisVascular Access Function 1 2 3 4 Arterial and Venous Pressures 1 2 3 4 Blood Flow Rate 1 2 3 4 Management of Anticoagulation 1 2 3 4 Conductivity 1 2 3 4 Ultra Filtration Calculation 1 2 3 4 Operation of Myron L. Meter 1 2 3 4 Administration of Blood and Blood Products 1 2 3 4 Administration of Mannitol 1 2 3 4 Sequential Ultrafiltration/PUF 1 2 3 4 Patient ManagementFluid Overload 1 2 3 4 Hypertension 1 2 3 4 Hypotension 1 2 3 4 Disequilibrium Syndrome 1 2 3 4 Hyperkalemia 1 2 3 4 Seizures 1 2 3 4 Muscle Cramps 1 2 3 4 Clotted Access/Poor Blood Flow Rate from Catheter 1 2 3 4 Pyrogenic Reaction 1 2 3 4 Hemolysis 1 2 3 4 Air Embolus 1 2 3 4 Chest Pain 1 2 3 4 Anemia 1 2 3 4 Neuropathy 1 2 3 4 Pericarditis 1 2 3 4 Filter Blood Leak 1 2 3 4 Cardiopulmonary Arrest 1 2 3 4 Anticoagulation Emergencies 1 2 3 4 Dialysis EquipmentBaxter 1 2 3 4 Cobe 1 2 3 4 Fresenius H/K 1 2 3 4 Gambro 1 2 3 4 Phoenix 1 2 3 4 T Machine 1 2 3 4 Other Dialysis Equipment Professional Knowledge & SkillsNational Patient Safety Goals 1 2 3 4 Patient Isolation/Infection Prevention 1 2 3 4 Management of Dialysis Equipment Alarms 1 2 3 4 Bedside Blood Glucose Monitoring 1 2 3 4 Pyxis Medication Admin System 1 2 3 4 Computerized Charting 1 2 3 4 Proton Charting Experience 1 2 3 4 AMI Charting Experience 1 2 3 4 Ecube Charting Experience 1 2 3 4 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 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 CertificationsBLS Yes BLS Expiration Date Month Day Year CNRN Yes CNRN Expiration Date Month Day Year ACLS Yes ACLS Expiration Date Month Day Year CCRN Yes CCRN Expiration Date Month Day Year Other: Specify Other Expiration Date Month Day Year 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 Dialysis Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
