CVOR RN

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Name*

First Last

Phone*

Email*

Age Specific Care

Proficiency Rating

Frequency Rating

Newborn/Neonate (birth - 30 days) *

Newborn/Neonate (birth - 30 days) proficiency*

Newborn/Neonate (birth - 30 days) frequency*

Infant (30 days - 1 year) *

Infant (30 days - 1 year) proficiency*

Infant (30 days - 1 year) frequency*

Toddler (1 - 3 years) *

Toddler (1 - 3 years) proficiency*

Toddler (1 - 3 years) frequency*

Preschooler (3 - 5 years) *

Preschooler (3 - 5 years) proficiency*

Preschooler (3 - 5 years) frequency*

School Age Child (5 - 12 years) *

School Age Child (5 - 12 years) proficiency*

School Age Child (5 - 12 years) frequency*

Adolescents (12 - 18 years) *

Adolescents (12 - 18 years) proficiency*

Adolescents (12 - 18 years) frequency*

Young Adults (18 - 39 years) *

Young Adults (18 - 39 years) proficiency*

Young Adults (18 - 39 years) frequency*

Middle Adults (39 - 64 years) *

Middle Adults (39 - 64 years) proficiency*

Middle Adults (39 - 64 years) frequency*

Older Adults (64+ years) *

Older Adults (64+ years) proficiency*

Older Adults (64+ years) frequency*

Elderly Adults (over 79+ years) *

Elderly Adults (over 79+ years) proficiency*

Elderly Adults (over 79+ years) frequency*

Settings

Proficiency Rating

Frequency Rating

Operating Room *

Operating Room proficiency*

Operating Room frequency*

Clinic *

Clinic proficiency*

Clinic frequency*

General Skills

Proficiency Rating

Frequency Rating

Crash Cart *

Crash Cart proficiency*

Crash Cart frequency*

Universal Protocol *

Universal Protocol proficiency*

Universal Protocol frequency*

Patient Identification *

Patient Identification proficiency*

Patient Identification frequency*

Hand-off Communication *

Hand-off Communication proficiency*

Hand-off Communication frequency*

Standard Precautions *

Standard Precautions proficiency*

Standard Precautions frequency*

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Pediatric Respiratory / Cardiac Arrest *

Pediatric Respiratory / Cardiac Arrest proficiency*

Pediatric Respiratory / Cardiac Arrest frequency*

Adult Respiratory / Cardiac Arrest *

Adult Respiratory / Cardiac Arrest proficiency*

Adult Respiratory / Cardiac Arrest frequency*

Adult Respiratory / Cardiac Arrest *

Adult Respiratory / Cardiac Arrest proficiency*

Adult Respiratory / Cardiac Arrest frequency*

Automated Med Dispensing Systems *

Automated Med Dispensing Systems proficiency*

Automated Med Dispensing Systems frequency*

List Types:

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Assessment And Patient Care

Proficiency Rating

Frequency Rating

CIRCULATING DUTIES

Computerized Documentation *

Computerized Documentation proficiency*

Computerized Documentation frequency*

Develop Plan of Care *

Develop Plan of Care proficiency*

Develop Plan of Care frequency*

Informed Consent *

Informed Consent proficiency*

Informed Consent frequency*

Level of Consciousness *

Level of Consciousness proficiency*

Level of Consciousness frequency*

Patient / Family Teaching *

Patient / Family Teaching proficiency*

Patient / Family Teaching frequency*

Perioperative Assessment *

Perioperative Assessment proficiency*

Perioperative Assessment frequency*

Skin Assessment *

Skin Assessment proficiency*

Skin Assessment frequency*

Time-Out Procedure *

Time-Out Procedure proficiency*

Time-Out Procedure frequency*

CHEST / THORACIC

A-F Bypass *

A-F Bypass proficiency*

A-F Bypass frequency*

Abdominal Aortic Aneurysm (open) *

Abdominal Aortic Aneurysm (open) proficiency*

Abdominal Aortic Aneurysm (open) frequency*

A-V Access Graft *

A-V Access Graft proficiency*

A-V Access Graft frequency*

Aortic Stent Insertion *

Aortic Stent Insertion proficiency*

Aortic Stent Insertion frequency*

Ascending / Thoracic Aneurysm *

Ascending / Thoracic Aneurysm proficiency*

Ascending / Thoracic Aneurysm frequency*

Biopsy *

Biopsy proficiency*

Biopsy frequency*

Carotid Endarterectomy *

Carotid Endarterectomy proficiency*

Carotid Endarterectomy frequency*

Chest Trauma *

Chest Trauma proficiency*

Chest Trauma frequency*

Coronary Artery Bypass Graft *

Coronary Artery Bypass Graft proficiency*

Coronary Artery Bypass Graft frequency*

Embolectomy *

Embolectomy proficiency*

Embolectomy frequency*

Fem-Fem *

Fem-Fem proficiency*

Fem-Fem frequency*

Fem-Pop Bypass *

Fem-Pop Bypass proficiency*

Fem-Pop Bypass frequency*

Heart Transplant *

Heart Transplant proficiency*

Heart Transplant frequency*

Implantable Cardioverter Defibrillator *

Implantable Cardioverter Defibrillator proficiency*

Implantable Cardioverter Defibrillator frequency*

Mitral or Aortic Valve Replacement / Repair *

Mitral or Aortic Valve Replacement / Repair proficiency*

Mitral or Aortic Valve Replacement / Repair frequency*

Pacemaker Insertion *

Pacemaker Insertion proficiency*

Pacemaker Insertion frequency*

Patent Ductus Arteriosus *

Patent Ductus Arteriosus proficiency*

Patent Ductus Arteriosus frequency*

Pneumonectomy *

Pneumonectomy proficiency*

Pneumonectomy frequency*

Rib Resection *

Rib Resection proficiency*

Rib Resection frequency*

Septal Defect Repairs *

Septal Defect Repairs proficiency*

Septal Defect Repairs frequency*

Thorocotomy *

Thorocotomy proficiency*

Thorocotomy frequency*

Vena Cava Filter *

Vena Cava Filter proficiency*

Vena Cava Filter frequency*

Thoracic Stent Insertion *

Thoracic Stent Insertion proficiency*

Thoracic Stent Insertion frequency*

Vena Cava Ligation *

Vena Cava Ligation proficiency*

Vena Cava Ligation frequency*

Medications / Therapeutic Interventions

Proficiency Rating

Frequency Rating

IV THERAPY

Admin Blood / Blood Products *

Admin Blood / Blood Products proficiency*

Admin Blood / Blood Products frequency*

Assist with IA/IV Therapy *

Assist with IA/IV Therapy proficiency*

Assist with IA/IV Therapy frequency*

Starting IVs *

Starting IVs proficiency*

Starting IVs frequency*

Vascular Access Device Management *

Vascular Access Device Management proficiency*

Vascular Access Device Management frequency*

Assist with Insertion of Invasive Devices (Arterial / CVP / Swan Ganz) *

Assist with Insertion of Invasive Devices (Arterial / CVP / Swan Ganz) proficiency*

Assist with Insertion of Invasive Devices (Arterial / CVP / Swan Ganz) frequency*

PAIN MANAGEMENT / ANESTHESIA

Ventilator *

Ventilator proficiency*

Ventilator frequency*

Assess Pain Level / Tolerance *

Assess Pain Level / Tolerance proficiency*

Assess Pain Level / Tolerance frequency*

Epidural Anesthesia / Anagelsia *

Epidural Anesthesia / Anagelsia proficiency*

Epidural Anesthesia / Anagelsia frequency*

Anesthesia Toxicity *

Anesthesia Toxicity proficiency*

Anesthesia Toxicity frequency*

General *

General proficiency*

General frequency*

Regional *

Regional proficiency*

Regional frequency*

Spinal *

Spinal proficiency*

Spinal frequency*

Signs and Symptoms of Dural Puncture *

Signs and Symptoms of Dural Puncture proficiency*

Signs and Symptoms of Dural Puncture frequency*

Positioning Patients *

Positioning Patients proficiency*

Positioning Patients frequency*

Moderate Sedation *

Moderate Sedation proficiency*

Moderate Sedation frequency*

Induction *

Induction proficiency*

Induction frequency*

Procedures / Equipment

Proficiency Rating

Frequency Rating

PROCEDURES

Airway Maintenance *

Airway Maintenance proficiency*

Airway Maintenance frequency*

Arterial Line Monitoring *

Arterial Line Monitoring proficiency*

Arterial Line Monitoring frequency*

Aseptic Technique *

Aseptic Technique proficiency*

Aseptic Technique frequency*

Cricoid Pressure *

Cricoid Pressure proficiency*

Cricoid Pressure frequency*

Donning of Surgical Attire *

Donning of Surgical Attire proficiency*

Donning of Surgical Attire frequency*

Foley Catheterization *

Foley Catheterization proficiency*

Foley Catheterization frequency*

Hemodynamic Monitoring *

Hemodynamic Monitoring proficiency*

Hemodynamic Monitoring frequency*

IABP *

IABP proficiency*

IABP frequency*

Implantable Cardioverter Defibrillator *

Implantable Cardioverter Defibrillator proficiency*

Implantable Cardioverter Defibrillator frequency*

Pacemaker Insertion *

Pacemaker Insertion proficiency*

Pacemaker Insertion frequency*

Patient Charge Capture Systems *

Patient Charge Capture Systems proficiency*

Patient Charge Capture Systems frequency*

Patient Positioning *

Patient Positioning proficiency*

Patient Positioning frequency*

Patient Prep *

Patient Prep proficiency*

Patient Prep frequency*

Procedure Set Up *

Procedure Set Up proficiency*

Procedure Set Up frequency*

Equipment, Sponge and Lab Counts *

Equipment, Sponge and Lab Counts proficiency*

Equipment, Sponge and Lab Counts frequency*

EQUIPMENT

Bair Hugger *

Bair Hugger proficiency*

Bair Hugger frequency*

Blood and Fluid Warmer *

Blood and Fluid Warmer proficiency*

Blood and Fluid Warmer frequency*

Bovie *

Bovie proficiency*

Bovie frequency*

Cell Saver / Auro-Transfuser *

Cell Saver / Auro-Transfuser proficiency*

Cell Saver / Auro-Transfuser frequency*

Chest Drainage System *

Chest Drainage System proficiency*

Chest Drainage System frequency*

Defibrillator / Internal Paddles *

Defibrillator / Internal Paddles proficiency*

Defibrillator / Internal Paddles frequency*

Electrosurgical Unit *

Electrosurgical Unit proficiency*

Electrosurgical Unit frequency*

Emerson Thoracic Pump *

Emerson Thoracic Pump proficiency*

Emerson Thoracic Pump frequency*

Flexible Bronchoscope *

Flexible Bronchoscope proficiency*

Flexible Bronchoscope frequency*

Laser *

Laser proficiency*

Laser frequency*

Pneumatic Tourniquet *

Pneumatic Tourniquet proficiency*

Pneumatic Tourniquet frequency*

Suction Units (Neptune, Wall) *

Suction Units (Neptune, Wall) proficiency*

Suction Units (Neptune, Wall) frequency*

Ultrasonic Cleaner *

Ultrasonic Cleaner proficiency*

Ultrasonic Cleaner frequency*

Sterad Machine *

Sterad Machine proficiency*

Sterad Machine frequency*

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Skills/Competences

Proficiency

Frequency

CVOR RN

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