Echo

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Name*

First Last

Phone*

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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*

Adult Echo

Proficiency Rating

Frequency Rating

Routine *

Routine proficiency*

Routine frequency*

3-D Echo *

3-D Echo proficiency*

3-D Echo frequency*

Pedoff Probe *

Pedoff Probe proficiency*

Pedoff Probe frequency*

Transesophageal Echo *

Transesophageal Echoproficiency*

Transesophageal Echo frequency*

Stress Echo *

Stress Echo proficiency*

Stress Echo frequency*

Post-Cath Echo *

Post-Cath Echo proficiency*

Post-Cath Echo frequency*

Post-Surgical Echo *

Post-Surgical Echo proficiency*

Post-Surgical Echo frequency*

Imaging with Contrast Agents *

Imaging with Contrast Agents proficiency*

Imaging with Contrast Agents frequency*

2-Dimensional *

2-Dimensional proficiency*

2-Dimensional frequency*

M-Mode *

M-Mode proficiency*

M-Mode frequency*

PW Doppler *

PW Doppler proficiency*

PW Doppler frequency*

CW Doppler *

CW Doppler proficiency*

CW Doppler frequency*

Parasternal Long Axis View *

Parasternal Long Axis View proficiency*

Parasternal Long Axis View frequency*

Parasternal Short Axis View *

Parasternal Short Axis View proficiency*

Parasternal Short Axis View frequency*

Right Ventricular Inflow Tract (RVIT) *

Right Ventricular Inflow Tract (RVIT) proficiency*

Right Ventricular Inflow Tract (RVIT) frequency*

Right Ventricular Outflow Tract (RVOT) *

Right Ventricular Outflow Tract (RVOT) proficiency*

Right Ventricular Outflow Tract (RVOT) frequency*

2-Chamber View *

2-Chamber View proficiency*

2-Chamber View frequency*

4-Chamber View *

4-Chamber View proficiency*

4-Chamber View frequency*

Diastolic Dysfunction Evaluation *

Diastolic Dysfunction Evaluation proficiency*

Diastolic Dysfunction Evaluation frequency*

Subcostal View *

Subcostal View proficiency*

Subcostal View frequency*

Suprasternal View *

Suprasternal View proficiency*

Suprasternal View frequency*

Cardiac Anatomy *

Cardiac Anatomy proficiency*

Cardiac Anatomy frequency*

Assessment of Endocardium *

Assessment of Endocardium proficiency*

Assessment of Endocardium frequency*

Continuity Equation *

Continuity Equation proficiency*

Continuity Equation frequency*

Pedoff Probe in Apical *

Pedoff Probe in Apical proficiency*

Pedoff Probe in Apical frequency*

Pedoff Probe in Suprasternal *

Pedoff Probe in Suprasternal proficiency*

Pedoff Probe in Suprasternal frequency*

Pedoff Probe in Parasternal Right *

Pedoff Probe in Parasternal Right proficiency*

Pedoff Probe in Parasternal Right frequency*

Bubble Studies *

Bubble Studies proficiency*

Bubble Studies frequency*

Definity Studies *

Definity Studies proficiency*

Definity Studies frequency*

Treadmill Stress *

Treadmill Stress proficiency*

Treadmill Stress frequency*

Dobutamine Stress *

Dobutamine Stress proficiency*

Dobutamine Stress frequency*

Left hand scanner *

Left hand scanner proficiency*

Left hand scanner frequency*

Pediatric Echo

Proficiency Rating

Frequency Rating

Pediatric Anomalies *

Pediatric Anomalies proficiency*

Pediatric Anomalies frequency*

Pediatric Post-Surgical Scans *

Pediatric Post-Surgical Scans proficiency*

Pediatric Post-Surgical Scans frequency*

Children’s Hospital Experience *

Children’s Hospital Experience proficiency*

Children’s Hospital Experience frequency*

Miscellaneous

Proficiency Rating

Frequency Rating

12-Lead ECG *

12-Lead ECG proficiency*

12-Lead ECG frequency*

EKG *

EKG proficiency*

EKG frequency*

Holter Monitor *

Holter Monitor proficiency*

Holter Monitor frequency*

Equipment

Proficiency Rating

Frequency Rating

Acuson *

Acuson proficiency*

Acuson frequency*

Philips/ATL *

Philips/ATL proficiency*

Philips/ATL frequency*

GE *

GE proficiency*

GE frequency*

Siemens *

Siemens proficiency*

Siemens frequency*

Toshiba *

Toshiba proficiency*

Toshiba frequency*

Computer Systems

Proficiency Rating

Frequency Rating

AGFA *

AGFA proficiency*

AGFA frequency*

Fuji *

Fuji proficiency*

Fuji frequency*

GE *

GE proficiency*

GE frequency*

Siemens *

Siemens proficiency*

Siemens frequency*

Epic *

Epic proficiency*

Epic frequency*

Cerner *

Cerner proficiency*

Cerner frequency*

Meditech *

Meditech proficiency*

Meditech frequency*

McKesson *

McKesson proficiency*

McKesson frequency*

General Skills

Proficiency Rating

Frequency Rating

Patients in Restraints *

Patients in Restraints proficiency*

Patients in Restraints frequency*

Lifting/Transfer Devices *

Lifting/Transfer Devices proficiency*

Lifting/Transfer Devices frequency*

Cardiac Arrest/CPR *

Cardiac Arrest/CPR proficiency*

Cardiac Arrest/CPR frequency*

Use of Rapid Response Teams *

Use of Rapid Response Teams proficiency*

Use of Rapid Response Teams frequency*

National Patient Safety Goals

Proficiency Rating

Frequency Rating

Accurate Patient Identification *

Accurate Patient Identification proficiency*

Accurate Patient Identification frequency*

Effective Communication *

Effective Communication proficiency*

Effective Communication frequency*

Infection Control *

Infection Control proficiency*

Infection Control frequency*

Universal Precautions *

Universal Precautions proficiency*

Universal Precautions frequency*

Patients in Isolation *

Patients in Isolation proficiency*

Patients in Isolation frequency*

Minimize Risk for Fall *

Minimize Risk for Fall proficiency*

Minimize Risk for Fall frequency*

Work Settings

Proficiency Rating

Frequency Rating

Adult Acute Care *

Adult Acute Care proficiency*

Adult Acute Care frequency*

Adult Outpatient *

Adult Outpatient proficiency*

Adult Outpatient frequency*

Pediatric Acute Care *

Pediatric Acute Care proficiency*

Pediatric Acute Care frequency*

Pediatric Outpatient *

Pediatric Outpatient proficiency*

Pediatric Outpatient frequency*

ER/ICU *

ER/ICU proficiency*

ER/ICU frequency*

Level I Trauma *

Level I Trauma proficiency*

Level I Trauma frequency*

Level II Trauma *

Level II Trauma proficiency*

Level II Trauma frequency*

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Skills/Competences

Proficiency

Frequency

ECHO

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