Emergency Room

Requested by *

Recruiter Email ID *

First Name *

Last Name *

Phone Number *

Today's Date *

Your Email Address *

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Academic/Teaching Facility *

Trauma Center *

Inpatient Acute Care Facility *

Outpatient Care Facility *

Long term care/Skilled Nursing *

Clinic/Ambulatory *

Home Health Setting *

GENERAL SKILLS:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Advanced directives *

HIPAA *

Patient/family teaching *

Restrictive devices (restraints) *

Lift/transfer devices *

Specialty beds *

End of life care/palliative care *

Post mortem care *

Automated Medication Dispensing System, Pyxis, Omnicell, or other *

Bar coding for medication administration *

Triage *

Organ donor protocols *

Consent for treatment of a minor *

Procedure for a patient signing out AMA *

Knowledge of cobra criteria/transfer patients *

Disaster protocols *

National Patient Safety Goals *

Accurate patient identification *

Effective communication *

Interpretation & communication of lab values *

Medication administration *

Labeling *

Anticoagulation therapy *

Medication reconciliation *

Monitoring conscious sedation *

Pain assessment & management *

Infection control *

Universal precautions *

Isolation *

Minimize risk for falls *

Awareness of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) *

Prevention of pressure ulcers *

Wound care *

Suture tray set up *

CARDIAC MONITORING & EMERGENCY CARE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Obtains 12 lead EKG *

Interpretation of rhythm strips *

Treatment of dysrhythmias *

Use of rapid response teams *

Cardiac arrest/CPR *

Code cart set up and shift checks *

O2 therapy & delivery *

Pulse oximetry *

Use of doppler *

IV THERAPY:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Starting & maintaining peripheral IVs *

Blood draw: venous *

Central line care *

Blood draw: central line *

Care & management of ports *

Care & management of PICC /Groshong / Hickman *

Administration of blood / blood products *

Diabetes mellitus *

Blood Glucose Monitoring (BGM) *

Insulin administration *

TRAUMA EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Trauma score *

Critical transports *

Air transport (helicopter or jet) *

Other transport experience *

Level 1 trauma *

Level 2 trauma *

Level 1 infuser *

Open chest massage *

Peritoneal lavage *

Hypovolemic shock *

H+H / stat lab test machine *

Post drowning *

Auto transfuser / warmer *

BURN EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

First degree *

Second degree *

Third degree *

Electrocution *

Hazardous material exposure / contamination *

Calculation of total Body Surface Area (BSA) *

RESPIRATORY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Pulmonary edema *

C.O.P.D. *

Pulmonary emboli *

Near drowning *

Asthma *

Nebulizer *

Pneumonia *

ABG interpretation *

AIRWAY MANAGEMENT, CARE & MAINTENANCE OF:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Oral / NT / ET airway *

Tracheostomy *

Obtaining ABG blood sample/arterial line *

Pulse Oximetry *

Capnography *

VENTILATOR MANAGEMENT:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

BiPAP (Bi-level Positive Airway Pressure) *

Oscillation / high-frequency ventilation *

Nitric *

Interpretation of weaning parameters *

VASCULAR ACCESS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Assist with intraosseous needle insertion *

Assisting with a cut-down *

Assist with central line insertion *

Assist with arterial line insertion *

ASSIST WITH INSERTION & or MANAGEMENT OF:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Manage Care of CVC (Central Venous Catheter) *

Manage Care of Arterial line *

CARDIOVASCULAR EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Acute MI *

Unstable angina *

Aneurysm (thoracic or abdominal) *

CHF *

Cardioversion *

Defibrillation *

Assist with insertion of a temporary pacemaker *

Application of an external pacemaker *

Cardiogenic shock *

NEUROLOGICAL EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

NEUROLOGICAL EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Neuro assessment / monitoring *

Use of Glasgow Coma Scale *

Traumatic Brain Injury (TBI) *

Acute T.I.A. / C.V.A. *

Acute spinal injury *

Migraine headache *

Seizure precautions / status epilepticus *

Assist with lumbar puncture *

Transport of a patient with spinal cord injuries/cervical spine precautions *

Observing for increased intracranial pressure *

GASTROINTESTINAL EXPERIENCE - CARE OF PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

GI and GU Bleed *

Abdominal pain *

NGT insertion *

G-tube *

J-tube *

Bowel obstruction *

Acute pancreatitis *

Testicular torsion *

OBSTETRICS/GYNECOLOGY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Assist with pelvic exams / obtaining cultures *

Spontaneous abortion / hemorrhage *

Ectopic pregnancy *

Emergency delivery *

Placenta previa *

Preeclampsia / eclampsia *

Doppler FHT (Fetal Heart Tones) *

PEDIATRICS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Pediatric arrest / resuscitation *

Use of Broslow resuscitation system *

Overdose / poison ingestion *

Child abuse *

Sepsis management *

Sickle cell anemia *

Peds IV periph starts *

Pediatric assessment/VS *

RENAL EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Acute renal failure *

Chronic renal failure *

Peritoneal dialysis *

Fluid management / electrolyte replacement *

Renal calculi *

Foley cath / straight cath / clean cath urine *

ORTHOPEDICS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Set up for cast application *

Set up for OCL splinting *

Assist with closed fracture / dislocation reductions *

Instruction of application of orthopedic appliances *

Assess extremity vascular circulation *

PSYCHIATRIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Drug/ETOH withdrawal *

Care of overdose patient / gastric lavage *

Care of a suicidal patient *

Crisis intervention / management & assaultive behavior *

Sexual assault *

Rape kit *

Reporting procedures for acts of violence *

ENVIRONMENT EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Hypothermia *

Heat stroke / exhaustion *

Human / animal bite *

Snake bite *

Anaphylaxis *

EENT DISORDERS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Set up for fluorescein / woods lamp *

Use of Morgan Lens / eye irrigation *

Ear irrigations / FB removal *

Assist with nasal packing *

Visual acuity *

Epiglottitis *

Nose bleed / packing *

Removal of nasal FB *

EMERGENCY MEDICATIONS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Emergency ACLS medication prepare & administer *

Tridil / nitroglycerin *

Sodium bicarb *

Heparin *

Dilantin / cerebrex *

Narcan *

Decadron *

Mannitol *

Solumedrol *

Phenobarbital *

Fibrinolytics / IIb IIIa inhibitor *

Nipride / cardene *

Inotropics (i.e. digoxin, dopamine, epinephrine) *

Rapid sequence intubation protocol & meds *

Diprivan *

Cardizem *

Vasopressin *

Romazicon *

Levophed *

Insulin / insulin GTT *

AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Newborn / neonate (birth-30 days) *

Infant (31 days-1 year) *

Toddler (ages 2-3 years) *

Preschool (ages 4-5 years) *

School age (ages 6-12 years) *

Adolescent (ages 13-21 years) *

Young adult (ages 22-39 years) *

Adult (ages 40-64 years) *

Older adult (ages 65-79 years) *

Elderly (ages 80+ years) *