Respiratory Therapist

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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*

Patient Data Evaluation

Proficiency Rating

Frequency Rating

Collect and evaluate pertinent patient clinical data *

Collect and evaluate pertinent patient clinical data proficiency*

Collect and evaluate pertinent patient clinical data frequency*

Integrate individualized interview techniques to determine patient’s overall health status *

Integrate individualized interview techniques to determine patient’s overall health status proficiency*

Integrate individualized interview techniques to determine patient’s overall health status frequency*

Perform a comprehensive physical examination on patient *

Perform a comprehensive physical examination on patient proficiency*

Perform a comprehensive physical examination on patient frequency*

Auscultate Breath sounds *

Auscultate Breath sounds proficiency*

Auscultate Breath sounds frequency*

Assess Rate & Work of breathing *

Assess Rate & Work of breathing proficiency*

Assess Rate & Work of breathing frequency*

Recognize normal and abnormal results of cardiopulmonary monitoring *

Recognize normal and abnormal results of cardiopulmonary monitoring proficiency*

Recognize normal and abnormal results of cardiopulmonary monitoring frequency*

Identify normal and abnormal cough, sputum amount, color, and character *

Identify normal and abnormal cough, sputum amount, color, and character proficiency*

Identify normal and abnormal cough, sputum amount, color, and character frequency*

Perform palpation techniques to determine patient’s cardiopulmonary status *

Perform palpation techniques to determine patient’s cardiopulmonary statusproficiency*

Perform palpation techniques to determine patient’s cardiopulmonary status frequency*

Assess Peak flow rate *

Assess Peak flow rate proficiency*

Assess Peak flow rate frequency*

Perform Pulmonary function testing *

Perform Pulmonary function testing proficiency*

Perform Pulmonary function testing frequency*

Obtaining ABGs *

Obtaining ABGs proficiency*

Obtaining ABGs frequency*

Brachial artery *

Brachial artery proficiency*

Brachial artery frequency*

Femoral artery *

Femoral artery proficiency*

Femoral artery frequency*

Radial artery *

Radial artery proficiency*

Radial artery frequency*

Perform Allen test *

Perform Allen test proficiency*

Perform Allen test frequency*

Blood Sample from arterial line *

Blood Sample from arterial line proficiency*

Blood Sample from arterial line frequency*

Interpretation of lab results *

Interpretation of lab results proficiency*

Interpretation of lab results frequency*

Arterial blood gases *

Arterial blood gases proficiency*

Arterial blood gases frequency*

Basic EKG *

Basic EKG proficiency*

Basic EKG frequency*

Blood chemistry *

Blood chemistry proficiency*

Blood chemistry frequency*

Chest X-ray *

Chest X-ray proficiency*

Chest X-ray frequency*

Perform arterial line insertion *

Perform arterial line insertion proficiency*

Perform arterial line insertion frequency*

12-Lead EKG *

12-Lead EKG proficiency*

12-Lead EKG frequency*

Chest Physiotherapy *

Chest Physiotherapy proficiency*

Chest Physiotherapy frequency*

Vent set-up and care *

Vent set-up and care proficiency*

Vent set-up and care frequency*

Assist with Thoracentesis *

Assist with Thoracentesis proficiency*

Assist with Thoracentesis frequency*

Provision of Care

Proficiency Rating

Frequency Rating

Acute/chronic bronchitis *

Acute/chronic bronchitis proficiency*

Acute/chronic bronchitis frequency*

ARDS (Adult Respiratory Distress Syndrome) *

ARDS (Adult Respiratory Distress Syndrome) proficiency*

ARDS (Adult Respiratory Distress Syndrome) frequency*

Aspiration *

Aspiration proficiency*

Aspiration frequency*

Asthma *

Asthma proficiency*

Asthma frequency*

Bronchoscopy *

Bronchoscopy proficiency*

Bronchoscopy frequency*

Cardiac Surgery *

Cardiac Surgery proficiency*

Cardiac Surgery frequency*

CHF *

CHF proficiency*

CHF frequency*

Care of patient with a chest tube *

Care of patient with a chest tube proficiency*

Care of patient with a chest tube frequency*

COPD *

COPD proficiency*

COPD frequency*

Cystic fibrosis *

Cystic fibrosis proficiency*

Cystic fibrosis frequency*

Epiglottitis *

Epiglottitis proficiency*

Epiglottitis frequency*

Fresh tracheostomy *

Fresh tracheostomy proficiency*

Fresh tracheostomy frequency*

Guillain Barre *

Guillain Barre proficiency*

Guillain Barre frequency*

Hemopneumothorax *

Hemopneumothorax proficiency*

Hemopneumothorax frequency*

Laryngospasm *

Laryngospasm proficiency*

Laryngospasm frequency*

Myasthenia Gravis *

Myasthenia Gravis proficiency*

Myasthenia Gravis frequency*

Pneumonia *

Pneumonia proficiency*

Pneumonia frequency*

Pneumothorax *

Pneumothorax proficiency*

Pneumothorax frequency*

Pulmonary Edema *

Pulmonary Edema proficiency*

Pulmonary Edema frequency*

Smoke inhalation *

Smoke inhalation proficiency*

Smoke inhalation frequency*

Status asthmaticus *

Status asthmaticus proficiency*

Status asthmaticus frequency*

Tension pneumothorax *

Tension pneumothorax proficiency*

Tension pneumothorax frequency*

Thoracotomy *

Thoracotomy proficiency*

Thoracotomy frequency*

Tracheo-esophageal fistula *

Tracheo-esophageal fistula proficiency*

Tracheo-esophageal fistula frequency*

Tuberculosis *

Tuberculosis proficiency*

Tuberculosis frequency*

Equipment Manipulation

Proficiency Rating

Frequency Rating

Select and assemble equipment related to support of the respiratory system *

Select and assemble equipment related to support of the respiratory system proficiency*

Select and assemble equipment related to support of the respiratory system frequency*

Bag and mask *

Bag and mask proficiency*

Bag and mask frequency*

ET Tube *

ET Tube proficiency*

ET Tube frequency*

CPAP *

CPAP proficiency*

CPAP frequency*

Face masks *

Face masks proficiency*

Face masks frequency*

Nasal Cannula *

Nasal Cannula proficiency*

Nasal Cannula frequency*

Nebulizer *

Nebulizer proficiency*

Nebulizer frequency*

Ultrasonic *

Ultrasonic proficiency*

Ultrasonic frequency*

Oxygen *

Oxygen proficiency*

Oxygen frequency*

T-piece *

T-piece proficiency*

T-piece frequency*

Trach collar *

Trach collar proficiency*

Trach collar frequency*

High frequency jet ventilator *

High frequency jet ventilator proficiency*

High frequency jet ventilator frequency*

High frequency oscillator *

High frequency oscillator proficiency*

High frequency oscillator frequency*

IMV *

IMV proficiency*

IMV frequency*

Inverse ratio ventilator *

Inverse ratio ventilator proficiency*

Inverse ratio ventilator frequency*

Pressure support *

Pressure support proficiency*

Pressure support frequency*

Pressure vents *

Pressure vents proficiency*

Pressure vents frequency*

SIMV *

SIMV proficiency*

SIMV frequency*

Trouble shooting high pressure alarms *

Trouble shooting high pressure alarms proficiency*

Trouble shooting high pressure alarms frequency*

Troubleshooting low pressure alarms *

Troubleshooting low pressure alarms proficiency*

Troubleshooting low pressure alarms frequency*

Volume vents *

Volume vents proficiency*

Volume vents frequency*

Weaning *

Weaning proficiency*

Weaning frequency*

PEEP *

PEEP proficiency*

PEEP frequency*

Breath Actuated Nebulizer *

Breath Actuated Nebulizer proficiency*

Breath Actuated Nebulizer frequency*

Venti-Masks *

Venti-Masks proficiency*

Venti-Masks frequency*

Troubleshoot equipment related to respiratory system support *

Troubleshoot equipment related to respiratory system support proficiency*

Troubleshoot equipment related to respiratory system support frequency*

High pressure vent alarms *

High pressure vent alarms proficiency*

High pressure vent alarms frequency*

Low pressure vent alarms *

Low pressure vent alarms proficiency*

Low pressure vent alarms frequency*

Oxygen-related equipment *

Oxygen-related equipment proficiency*

Oxygen-related equipment frequency*

Infection/Quality Control

Proficiency Rating

Frequency Rating

Perform QC (quality control) procedures for equipment *

Perform QC (quality control) procedures for equipment proficiency*

Perform QC (quality control) procedures for equipment frequency*

Maintain aseptic technique when applicable, ensuring infection control *

Maintain aseptic technique when applicable, ensuring infection control proficiency*

Maintain aseptic technique when applicable, ensuring infection control frequency*

Remove bronchopulmonary secretions *

Remove bronchopulmonary secretions proficiency*

Remove bronchopulmonary secretions frequency*

Documentation/Record Maintenance

Proficiency Rating

Frequency Rating

Review existing data in the patient record and document current information in record as it relates to current respiratory care plan *

Review existing data in the patient record and document current information in record as it relates to current respiratory care plan proficiency*

Review existing data in the patient record and document current information in record as it relates to current respiratory care plan frequency*

Airway Maintenance

Proficiency Rating

Frequency Rating

Function as an assistant to physician during special procedures *

Function as an assistant to physician during special procedures proficiency*

Function as an assistant to physician during special procedures frequency*

Initiate and conduct pulmonary rehabilitation with patient when indicated *

Initiate and conduct pulmonary rehabilitation with patient when indicated proficiency*

Initiate and conduct pulmonary rehabilitation with patient when indicated frequency*

Initiate and conduct emergency cardiopulmonary support, including BCLS, ACLS, PALS, and NRP when indicated *

Initiate and conduct emergency cardiopulmonary support, including BCLS, ACLS, PALS, and NRP when indicated proficiency*

Initiate and conduct emergency cardiopulmonary support, including BCLS, ACLS, PALS, and NRP when indicated frequency*

Nasal airway placement *

Nasal airway placement proficiency*

Nasal airway placement frequency*

Oral airway placement *

Oral airway placement proficiency*

Oral airway placement frequency*

Oropharyngeal/suctioning *

Oropharyngeal/suctioning proficiency*

Oropharyngeal/suctioning frequency*

Sputum specimen collection *

Sputum specimen collection proficiency*

Sputum specimen collection frequency*

Tracheostomy/suctioning *

Tracheostomy/suctioning proficiency*

Tracheostomy/suctioning frequency*

Incentive spirometry *

Incentive spirometry proficiency*

Incentive spirometry frequency*

Intubation *

Intubation proficiency*

Intubation frequency*

Intubation assistance *

Intubation assistance proficiency*

Intubation assistance frequency*

Extubation *

Extubation proficiency*

Extubation frequency*

Extubation assistance *

Extubation assistance proficiency*

Extubation assistance frequency*

Evaluation of Respiratory Care

Proficiency Rating

Frequency Rating

Perform venous, arterial, and capillary sticks for analyzing blood gases *

Perform venous, arterial, and capillary sticks for analyzing blood gases proficiency*

Perform venous, arterial, and capillary sticks for analyzing blood gases frequency*

Initiate patient education when indicated i.e.: MDI, nebulizer treatments *

ate patient education when indicated i.e.: MDI, nebulizer treatments proficiency*

ate patient education when indicated i.e.: MDI, nebulizer treatments frequency*

Modification/Recommendation of Respiratory Care

Proficiency Rating

Frequency Rating

Maintain and achieve adequate respiratory support for the patient *

Maintain and achieve adequate respiratory support for the patient proficiency*

Maintain and achieve adequate respiratory support for the patient frequency*

Evaluate and monitor patient’s objective and subjective responses to respiratory care *

Evaluate and monitor patient’s objective and subjective responses to respiratory care proficiency*

Evaluate and monitor patient’s objective and subjective responses to respiratory care frequency*

Modify treatment modalities based upon patient’s response to respiratory care *

Modify treatment modalities based upon patient’s response to respiratory care proficiency*

Modify treatment modalities based upon patient’s response to respiratory care frequency*

Recommend modifications to respiratory treatment when indicated *

Recommend modifications to respiratory treatment when indicated proficiency*

Recommend modifications to respiratory treatment when indicated frequency*

Initiate, conduct, or modify respiratory therapy treatments/techniques in an emergency setting *

Initiate, conduct, or modify respiratory therapy treatments/techniques in an emergency setting proficiency*

Initiate, conduct, or modify respiratory therapy treatments/techniques in an emergency setting frequency*

Neonatal/Pediatric Population

Proficiency Rating

Frequency Rating

Assist in high risk delivery *

Assist in high risk delivery proficiency*

Assist in high risk delivery frequency*

Capillary blood gases *

Capillary blood gases proficiency*

Capillary blood gases frequency*

Oxygen delivery system *

Oxygen delivery system proficiency*

Oxygen delivery system frequency*

Umbilical blood gases *

Umbilical blood gases proficiency*

Umbilical blood gases frequency*

Bronchopulmonary dysplasia (BPD) *

Bronchopulmonary dysplasia (BPD) proficiency*

Bronchopulmonary dysplasia (BPD) frequency*

Croup *

Croup proficiency*

Croup frequency*

Epiglottitis *

Epiglottitis proficiency*

Epiglottitis frequency*

Meconium aspiration *

Meconium aspiration proficiency*

Meconium aspiration frequency*

Near drowning *

Near drowning proficiency*

Near drowning frequency*

Persistent pulmonary hypertension *

Persistent pulmonary hypertension proficiency*

Persistent pulmonary hypertension frequency*

Respiratory interstitial emphysema *

Respiratory interstitial emphysema proficiency*

Respiratory interstitial emphysema frequency*

Respiratory distress syndrome *

Respiratory distress syndrome proficiency*

Respiratory distress syndrome frequency*

Respiratory syncytial virus *

Respiratory syncytial virus proficiency*

Respiratory syncytial virus frequency*

Transient tachypnea of the newborn *

Transient tachypnea of the newborn proficiency*

Transient tachypnea of the newborn frequency*

Medication Delivery System

Proficiency Rating

Frequency Rating

Aerosol heated/cooled *

Aerosol heated/cooled proficiency*

Aerosol heated/cooled frequency*

Aerosol set up mask *

Aerosol set up mask proficiency*

Aerosol set up mask frequency*

Aerosol set up trach *

Aerosol set up trach proficiency*

Aerosol set up trach frequency*

IPPB *

IPPB proficiency*

IPPB frequency*

Medihaler *

Medihaler proficiency*

Medihaler frequency*

Metered dose inhalers *

Metered dose inhalers proficiency*

Metered dose inhalers frequency*

Recognition of Medication Effects on Respiratory System

Proficiency Rating

Frequency Rating

Anectine *

Anectine proficiency*

Anectine frequency*

Atropine *

Atropine proficiency*

Atropine frequency*

Corticosteroids *

Corticosteroids proficiency*

Corticosteroids frequency*

Digitalis *

Digitalis proficiency*

Digitalis frequency*

Digoxin *

Digoxin proficiency*

Digoxin frequency*

Dopamine *

Dopamine proficiency*

Dopamine frequency*

Duramorph *

Duramorph proficiency*

Duramorph frequency*

Heliox therapy *

Heliox therapy proficiency*

Heliox therapy frequency*

Ketamine *

Ketamine proficiency*

Ketamine frequency*

Lidocaine *

Lidocaine proficiency*

Lidocaine frequency*

Morphine sulfate *

Morphine sulfate proficiency*

Morphine sulfate frequency*

Nipride *

Nipride proficiency*

Nipride frequency*

Nitric oxide therapy *

Nitric oxide therapy proficiency*

Nitric oxide therapy frequency*

Pavulon *

Pavulon proficiency*

Pavulon frequency*

Pentamide isethionate *

Pentamide isethionate proficiency*

Pentamide isethionate frequency*

Propofol *

Propofol proficiency*

Propofol frequency*

Theo-dur *

Theo-dur proficiency*

Theo-dur frequency*

Valium *

Valium proficiency*

Valium frequency*

Versed *

Versed proficiency*

Versed frequency*

Medication Administration

Proficiency Rating

Frequency Rating

Aerobid, Vanceril *

Aerobid, Vanceril proficiency*

Aerobid, Vanceril frequency*

Albuterol (Proventil, Ventolin) *

Albuterol (Proventil, Ventolin) proficiency*

Albuterol (Proventil, Ventolin) frequency*

Aminophylline (Theophylline) *

Aminophylline (Theophylline) proficiency*

Aminophylline (Theophylline) frequency*

Azmacort *

Azmacort proficiency*

Azmacort frequency*

Decadron *

Decadron proficiency*

Decadron frequency*

Flonase *

Flonase proficiency*

Flonase frequency*

Flovent *

Flovent proficiency*

Flovent frequency*

Inhaled steroids *

Inhaled steroids proficiency*

Inhaled steroids frequency*

Ipratropium bromide (Atrovent) *

Ipratropium bromide (Atrovent) proficiency*

Ipratropium bromide (Atrovent) frequency*

Isoetharine *

Isoetharine proficiency*

Isoetharine frequency*

Isoproterenol (Isuprel) *

Isoproterenol (Isuprel) proficiency*

Isoproterenol (Isuprel) frequency*

Mucomyst *

Mucomyst proficiency*

Mucomyst frequency*

Nasacort *

Nasacort proficiency*

Nasacort frequency*

Racemic epinephrine *

Racemic epinephrine proficiency*

Racemic epinephrine frequency*

Sodium Bicarbonate *

Sodium Bicarbonate proficiency*

Sodium Bicarbonate frequency*

Terbutaline sulfate *

Terbutaline sulfate proficiency*

Terbutaline sulfate frequency*

Xopenex *

Xopenex proficiency*

Xopenex frequency*

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Date*

Skills/Competences

Proficiency

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RESPIRATORY THERAPIST

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