Cardiovascular - Inverventional Skills Checklist

First name:	Last name:
Phone:	Email:
SSN (last 4 only):	Date: (MM/DD/YYYY)

Key - for each box mark:

Limited or no experience
Somewhat experienced but may need review
Can function independently
Competent to supervise

	1	2	3	4
ANGIOGRAPHY
Common Carotid
Vertebrobasilar (Intercranial)
Subclavian / vertebrals (extracranial)
Thoracic Aorta
Coronary
Ventriculography
Bypass Grafts
Pulmonary
Abdominal / Thoracic
Selective Visceral
Adrenal
Renal
Spinal
Inferior / Superior Vena Cava
Upper Extremity
Lower Extremity
Reproductive (female)
Reproductive (male)
Upper Extremity Venography
Lower Extremity Venography
Lymphangiography
Venous Sampling
Heart Catheterization
Cardiac Output
Electrophysiology Studies
Ventricular Volume Measurement
Myelography

	1	2	3	4
INTERVENTIONAL
Agioplasty
Stenting
Thrombolysis / Pharmacologic
Pericardiocentesis
TIPS
Embolization
Chemoembolization
Caval Filter Placements
Central Venous Access / Port Placement
Foreign Body Retrieval
Pressure Measurements
Biopsy
Permanent/Temporary pacemakers
Nephrostomy
Uteral Stents
Percutaneous Transhepatic Cholangiogram
Billary Drainage / Stenting
Abscess Drainage
Radiofrequency Ablation
Cholecystostomy
Enterostomy
General patient Care Procedures
Venipuncture / Contrast Admin
QA Procedures
Basic Life Support
Advanced Life Support

Age Specific Experiences and Certifications

Age Specific Experiences	Infants and Toddlers (birth-2 years)	Children (3-12 years)	Adolescent (13-18 years)	Young Adult (19-39 years)	Middle Adults (40-64 years)	Older Adult (65+ years)
1. Knows the normal growth and development for each age group and adapts care accordingly.
2. Knows the different communication needs for each age group and changes communication methods and terminology accordingly.
3. Knows the different safety risks for each age group and alters the environment accordingly.
4. Knows the different medications, dosages, and possible side effects for each age group and administers medications accordingly.

The information I have provided in this skills checklist is true and accurate to the best of my knowledge. I hereby authorize Fortus Group to release this information to client facilities in relation to consideration of my employment.