RN Endoscopy 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 independentlyProceduresAssist with EGD’s 1 2 3 4 Assist with endoscopic ultrasound 1 2 3 4 Assist with active GI bleed 1 2 3 4 Cautery devices 1 2 3 4 Assist with manometry studies 1 2 3 4 Assist with variceal banding 1 2 3 4 Assist with esophageal dilatations 1 2 3 4 Assist with esophageal ballooning 1 2 3 4 Assist with scelrotherapy 1 2 3 4 Assist with TEE 1 2 3 4 Assist with bronchoscopy 1 2 3 4 Assist with colonoscopy 1 2 3 4 Assist with polypectomy 1 2 3 4 Assist with ERCP’s 1 2 3 4 Assist with PEG placements 1 2 3 4 Assist with liver BX 1 2 3 4 Assist with collection of hot & cold BX’s 1 2 3 4 Specimen collection & labeling 1 2 3 4 Set up of scopes & video equipment 1 2 3 4 Apply external abdominal pressure to assist with scope movement 1 2 3 4 Scope cleaning 1 2 3 4 Assist with mobile cases, ICU, ER, etc. 1 2 3 4 Radiation safety 1 2 3 4 Automated Medication Dispensing System, Pyxis, Omnicell, or other 1 2 3 4 Takes call for emergency cases 1 2 3 4 National Patient Safety Goals 1 2 3 4 Awareness of HCAHPS 1 2 3 4 Accurate patient identification 1 2 3 4 Effective communication 1 2 3 4 Interpretation & communication of lab values 1 2 3 4 Medication administration 1 2 3 4 Labeling (medications & specimens) 1 2 3 4 Anticoagulation therapy 1 2 3 4 Monitoring conscious sedation 1 2 3 4 Pain assessment & management 1 2 3 4 Infection control 1 2 3 4 Universal precautions 1 2 3 4 Isolation 1 2 3 4 Minimize risk for falls 1 2 3 4 Prevention of pressure ulcers 1 2 3 4 Use of rapid response teams 1 2 3 4 Administer Conscious SedationFentanyl 1 2 3 4 Propofol 1 2 3 4 Demerol 1 2 3 4 Presedex 1 2 3 4 Versed 1 2 3 4 Reversal agents 1 2 3 4 Pre ProcedurePre procedure phone calls 1 2 3 4 Electronic documentation 1 2 3 4 Patient assessment 1 2 3 4 Colon prep or re-prep 1 2 3 4 Pre procedure checklist/consent 1 2 3 4 IV start, med admin 1 2 3 4 Post ProcedureAssess for air movement post colonoscopy 1 2 3 4 Assess for pain 1 2 3 4 Assess for bowel sounds 1 2 3 4 Assess for gag reflex post EGD 1 2 3 4 Assess for gag reflex post bronchoscopy 1 2 3 4 Recover from MAC 1 2 3 4 Recover from (moderate) conscious sedation 1 2 3 4 Discharge outpatients to home 1 2 3 4 Post procedure phone calls 1 2 3 4 Age Specific CompetenciesNewborn/neonate (Birth - 30 days) 1 2 3 4 Infant (31 days - 1 year) 1 2 3 4 Toddler (ages 2-3 years) 1 2 3 4 Preschooler (ages 4-5 years) 1 2 3 4 School age (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 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 RN Endoscopy Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
