GENERAL INFORMATION

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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 PACU 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

CARDIOVASCULAR

1

2

3

4

Open Heart Recovery

AAA Repair

Vascular Surgery

Pacemaker-Permanent & Temporary

Cardioversion

AICD Insertion

Cardiac Arrest

Cardiac Tamponade

CHF/Pulmonary Edema

Abnormal Heart Sounds/Murmurs

Pulses/Circulation Checks

PULMONARY

1

2

3

4

Fresh Tracheostomy

Thoracotomy/Lobectomy/Pneumonectomy

Pneumothorax/Hemothorax

Laryngospasm

Pulmonary Embolism

COPD

ABG Interpretation

NEUROLOGIC

1

2

3

4

Post Craniotomy

Anterior/Posterior Spinal Fusion

Carotid Endardarectomy

Spine Surgery

CVA

Stroke Scale

Glascow Coma Scale

Spinal Precautions

Hypothermia Protocol

Hypo/Hyperthermia Blanket

Sedation Scales/Levels

GASTROINTESTINAL

1

2

3

4

Pancreas/Liver Transplant

Colon Surgery

Colostomy/Ileostomy

ERCP

G Tube/J Tube Management

T Tube Management

RENAL/GENITOURINARY

1

2

3

4

Renal Surgery

TURP

Arteriovenous Fistula/Shunt

Nephrostomy Tubes

ENDOCRINE METABOLIC

1

2

3

4

Diabetes - Hypo/Hyperglycemic Crisis

IV Insulin Protocols

ORTHOPEDIC

1

2

3

4

Laminectomy

Total Joint Replacement

Amputation

Open Reduction/Internal Fixation

General Orthopedic Surgeries

CPM/Traction

Circulation Checks

WOUND MANAGEMENT

1

2

3

4

Surgical Drains

Wound Vac

Surgical Wound Assessment

Skin Assessment for Breakdown

Staging Decubitus Ulcers

MEDICATIONS

1

2

3

4

Procedural Sedation

Anesthesia Medications

Anti-Arrhythmics

Anticoagulants

Anti-Hypertensives

Anti-Seizure Medications

Benzodiazepines

Emergency Medications

Insulin

Narcotics/Opioid Analgesics

Nitrates

Non-Opioid Analgesics

Reversal Agents

Steroids

Automated Medication Dispensing (i.e. Pyxis, Omnicell)

IV THERAPY

1

2

3

4

Starting IVs

Central Line Blood Draws

Central Line/Implanted Line Care

Blood Product Administration

CARDIAC MONITORING & EMERG. RESPONSE

1

2

3

4

Malignant Hyperthermia

Dysrhythmia Interpretation

Dysrhythmia Management

12 Lead EKG

PROFESSIONAL KNOWLEDGE AND SKILLS

1

2

3

4

National Patient Safety Goals/Core Measures

Fall Risk Assessment/Prevention

Pressure Ulcer Risk Assessment/Prevention

Age Specific/Population-Based Care

Pain Assessment & Management

Charge Experience

Interpretation and Communication of Lab Values

Specialty Beds

EMR

1

2

3

4

EPIC

Cerner

Eclipsys

McKesson

Meditech

Other Computerized System

Computerized Physician Order Entry

Bar Coding for Medication Administration

EMR Conversion

Yes

No

Certifications

1

2

3

4

BLS

ACLS

PALS

Certification: CAPA or CPAN

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