GENERAL INFORMATION

Note: * Denotes a required field.

Please enter your full name as it appears on your Social Security Card: First Name   Middle Name   Last Name  * Please enter the Last Four digits of your Social Security Number:  -   -   *       Please check here if you do not hold a valid social security card. Please provide your contact information: Phone Number  * E-mail Address  * Confirm E-mail Address  * Type your e-mail address again above.

This profile is for use by healthcare professionals in the Cath Lab/Interventional Radiology Nursing discipline and specialty. It will not be a determining factor for the program.

CHECKLIST INSTRUCTIONS

Please mark your level of experience      1. No theory and/or experience      2. Limited experience/need supervision and/or support      3. Experienced/minimal support needed to perform      4. Proficient/can perform independently

WORK SETTING

1

2

3

4

Procedural Cath Lab

lnterventional Cath Lab

EP Lab

Interventional Radiology

Pre/Post Procedural Setting

Charge Experience

EQUIPMENT

1

2

3

4

Automatic Implantable Cardiac Defibrillator

Cardioversion

Defibrillation

Intra Aortic Balloon Pump (IABP)

SV02 Recording

Ventilator Management

CARDIAC CATH LAB PROCEDURES

1

2

3

4

AICD Placement

Aortography

Cardiac Biopsy

Cardiac Implant Closure Device

Cardiac Stent Placement

Diagnostic Cardiac Catheterization Adult

Diagnostic Cardiac Catheterization-Pediatric/Neonatal

Directional Coronary Atherectomy

IABP Placement/Removal

Internal Mammary Angiography

Laser Assisted Procedures

Percutaneous Transluminal Coronary Angioplasty

Pericardiocentesis

Permanent Pacemaker Placement

Pulmonary Angiography

Rotational Coronary Atherectomy

Saphenous Vein Graft Angiography

Transluminal Extraction Catheter

Valvuloplasty

Ventricular Assist Device Insertion

ELECTROPHYSIOLOGY PROCEDURES

1

2

3

4

Electrophysiology Evaluation

Baseline Measurements

Cardiac Ablation

Cardiac Mapping

Cardioversion

Conduction Study

Internal Cardioverter Defibrillator Implant

Tilt Table Study

IR-GASTROINTESTINAL STUDIES

1

2

3

4

Angioplasty

Chemoembolization

Cholecystostomy

Embolization

ERCP

Esophageal Stent Placement

Gastrojejunostomy

Gastrostomy Tube Placement

Liver Ablation

Pericentesis

Percutaneous Hepatic Angiography

TIPS

IR-GENITOURINARY STUDIES

1

2

3

4

Adrenal Angiography

Angiography of Female GU System

Angiography of Male GU System

Cystostomy

Embolization

Nephrostomy

Percutaneous Stone Extraction

Renal Angiography

Renal Artery Angioplasty

Renal Artery Stent Placement

Ureteral Stent

IR-NEUROLOGIC STUDIES

1

2

3

4

Cerebral Angiography

Carotid Angiography

Neurologic Angioplasty

Neurologic Thrombolysis

Vertebroplasty

IR-PERIPHERAL VASCULAR STUDIES

1

2

3

4

Abdominal Aortography

Angioplasty

Central Venous Access/Port Placement

Dialysis Graft Creation/Revision

Dialysis Graft lnterventional

Peripheral Vascular Embolization

Stent Graft Placement

SVC/IVC Venograph

Thoracic Aortography

Upper and Lower Extremity Angiography

IR-PULMONARY PROCEDURES

1

2

3

4

Chest Tube Placement

Pulmonary Embolization

Pulmonary Angiography

Thoracentesis

PROFESSIONAL KNOWLEDGE AND SKILLS

1

2

3

4

Conscious/Procedural Sedation

Assist w/Central Line/Venous Line Insertion

Venous Sampling

Topical Hemostasis (D-Stat, Chito-Seal, Syvek Patch, etc.)

Vascular Closure Systems (Perclose, StarClose, etc.)

External Compression Devices (C-Clamp, Sandbags,etc.)

Physiologic Monitoring/Recording

Sheath Removal and Monitoring

National Patient Safety Goals/Core Measures

Universal Protocol Procedures

Isolation Precautions

Infection Prevention

Age Specific/Population-Based Care

Fall Risk Assessment/Prevention

EMR

1

2

3

4

Cerner

Eclipsys

EPIC

GE

McKesson

Meditech

Other Computerized System

Computerized Physician Order Entry

Medication Administration using Bar Coding Technology

EMR Conversion

Yes

No

Certifications

1

2

3

4

BLS

ACLS

PALS

CCRN

Telemetry Certificate

Arrhythmia Course

Please read and agree to the statements below by marking the checkbox. You will not be able to submit until you have marked the checkbox. * I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize Hudson Staffing to release this Cath Lab/Interventional Radiology Nursing Skills Checklist to the client facilities in relation to consideration of employment as a healthcare professional with those facilities.

Privacy Note: Hudson Staffing will record anonymous electronic information about your connection when you click on the submit button. This information is used for security purposes only. This information will include your IP Address (54.166.172.180) which will be used as a digital signature.