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 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

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 PACU 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 (44.192.65.228) which will be used as a digital signature.