Skilled Nursing

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First Name *

Last Name *

Phone Number *

Today's Date *

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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 *

Hospital *

Occupational health *

Insurance company *

Outpatient Care Facility *

Long term care/Skilled Nursing *

Clinic/Ambulatory *

Home Health Setting *

GENERAL SKILLS EXPERIENCE

Rank each of the following sections on a scale of 1 to 5:

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

Advanced directives *

Awareness of HCAHPS *

Cardiac arrest / infant-child CPR *

Advanced directives *

Patient / family teaching *

Lift / transfer devices *

Specialty beds *

Restrictive devices (restraints) *

End of life care / palliative care *

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

Bar coding for medication administration *

Diabetic management in the OR *

National Patient Safety Goals *

Accurate patient identification *

Effective communication *

Time out protocol *

Interpretation & communication of lab values *

Labeling (medications & specimens) *

Medication reconciliation *

Anticoagulation therapy *

Monitoring conscious sedation *

Sedation / Anesthesia *

Infection control *

Universal precautions *

Isolation *

Minimize risk for falls *

Prevention of pressure ulcers *

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 *

DaVinci Procedures *

Aortic Valve Replacement *

Mitral Valve Repair/Replacement *

Multiple Valve Transposition *

Coronary Artery By Pass *

Pericardial Window *

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 *

Septal Defects *

Ventricular aneurysm repair *

Intra-Aortic Ballon insertion *

Bring Back Heart *

Aortic Arch Replacement *

Aortic Valve Conduit *

Thoraco Approach Mid-Cab *

Heartport or Similar CABG *

Mechanical Heart/ LVAD *

Chamberlain Procedure *

Femoral Artery Cannulation *

Gastric Artery Harvest *

Endoscopic Vein Harvest *

Saphenous Vein Harvest *

AICD Insertion *

Radial Vein Harvest *

Pacemaker Insertion *

AV Shunt *

Femoral-Popliteal By-Pass Graf *

Thrombectomy *

Abdominal Aortic Aneurysm *

Carotid Endarterectomy *

Pediatric Hearts *

Tetrology of Fallot *

Organ procurement *

CARDIAC EXPERIENCE: SCRUB

Rank each of the following sections on a scale of 1 to 5:

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

DaVinci Procedures *

Aortic Valve Replacement *

Mitral Valve Repair/Replacement *

Multiple Valve Transposition *

Coronary Artery By Pass *

Pericardial Window *

Septal Defects *

Ventricular aneurysm repair *

Intra-Aortic Ballon insertion *

Bring Back Heart *

Aortic Arch Replacement *

Aortic Valve Conduit *

Thoraco Approach Mid-Cab *

Heartport or Similar CABG *

Mechanical Heart/ LVAD *

Chamberlain Procedure *

Femoral Artery Cannulation *

Gastric Artery Harvest *

Endoscopic Vein Harvest *

Saphenous Vein Harvest *

AICD Insertion *

Radial Vein Harvest *

Pacemaker Insertion *

AV Shunt *

Femoral-Popliteal By-Pass Graf *

Thrombectomy *

Abdominal Aortic Aneurysm *

Carotid Endarterectomy *

Pediatric Hearts *

Tetrology of Fallot *

Organ procurement *

VASCULAR EXPERIENCE: CIRCULATE

Rank each of the following sections on a scale of 1 to 5:

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

Carotid Endarterectomy *

Abdominal Aoric Aneurysm *

Femoral-Popliteal By-Pass Graft (Insitu) *

AV Shunt *

Portacath, Tesio, Hickman *

Femoral-Popliteal By-Pass Graft (Graph) *

Thrombecomy *

Pacemaker Insertion *

Arterial Stenting *

Subclavian/Carotid By-Pass *

Intra-Operative Angioplast *

VASCULAR EXPERIENCE: SCRUB

Rank each of the following sections on a scale of 1 to 5:

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

Carotid Endarterectomy *

Abdominal Aoric Aneurysm *

Femoral-Popliteal By-Pass Graft (Insitu) *

AV Shunt *

Portacath, Tesio, Hickman *

Femoral-Popliteal By-Pass Graft (Graph) *

Thrombecomy *

Pacemaker Insertion *

Arterial Stenting *

Subclavian/Carotid By-Pass *

Intra-Operative Angioplast *

THORACIC CARDIOVASCULAR EXPERIENCE: CIRCULATE

Rank each of the following sections on a scale of 1 to 5:

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

Aortic Aneurysm *

Aortic-Femoral Bypass Graft *

Thoracotomy *

Thoracoscopy *

Mediastinoscopy *

Lobectomy *

Carotid Endarterectomy *

AV Shunt/Graf *

THORACIC CARDIOVASCULAR EXPERIENCE: SCRUB

Rank each of the following sections on a scale of 1 to 5:

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

Aortic Aneurysm *

Aortic-Femoral Bypass Graft *

Thoracotomy *

Thoracoscopy *

Mediastinoscopy *

Lobectomy *

Carotid Endarterectomy *

AV Shunt/Graf *

CIRCULATE/SCRUB: AGE-SPECIFIC EXPERIENCE

Rank each of the following sections on a scale of 1 to 5:

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) *