Cath EP

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Name*

First Last

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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*

Work Settings

Proficiency Rating

Frequency Rating

Procedural Cath Lab *

Procedural Cath Lab proficiency*

Procedural Cath Lab frequency*

Interventional Cath Lab *

Interventional Cath Lab proficiency*

Interventional Cath Lab frequency*

EP Lab *

EP Lab proficiency*

EP Lab frequency*

Pre/Post Procedural Setting *

Pre/Post Procedural Setting proficiency*

Pre/Post Procedural Setting frequency*

Charge/Lead Experience *

Charge/Lead Experience proficiency*

Charge/Lead Experience frequency*

Level I Trauma *

Level I Trauma proficiency*

Level I Trauma frequency*

Circulating

Proficiency Rating

Frequency Rating

Air Way Maintenance *

Air Way Maintenance proficiency*

Air Way Maintenance frequency*

Biopsy *

Biopsy proficiency*

Biopsy frequency*

Co-Ox Setup QC run sample *

Co-Ox Setup QC run sample proficiency*

Co-Ox Setup QC run sample frequency*

IABP *

IABP proficiency*

IABP frequency*

Recognize Cardiac waveform *

Recognize Cardiac waveform proficiency*

Recognize Cardiac waveform frequency*

LVEDP *

LVEDP proficiency*

LVEDP frequency*

Power Injector setup/use *

Power Injector setup/use proficiency*

Power Injector setup/use frequency*

PTCAs *

PTCAs proficiency*

PTCAs frequency*

Patient/Family Teaching pre-port *

Patient/Family Teaching pre-port proficiency*

Patient/Family Teaching pre-port frequency*

Left and Right Heart Catheterization *

Left and Right Heart Catheterization proficiency*

Left and Right Heart Catheterization frequency*

CLP Stent Implementation *

CLP Stent Implementation proficiency*

CLP Stent Implementation frequency*

Push Drugs ordered by MD *

Push Drugs ordered by MD proficiency*

Push Drugs ordered by MD frequency*

Radiation Protection *

Radiation Protection proficiency*

Radiation Protectionfrequency*

Directional Coronary Atherectomy *

Directional Coronary Atherectomy proficiency*

Directional Coronary Atherectomy frequency*

Permanent Pacemaker *

Permanent Pacemaker proficiency*

Permanent Pacemaker frequency*

Setting Threshold of Pacemakers *

Setting Threshold of Pacemakers proficiency*

Setting Threshold of Pacemakers frequency*

Transducer Setup/Calibration *

Transducer Setup/Calibration proficiency*

Transducer Setup/Calibration frequency*

Run Angio jet machine *

Run Angio jet machine proficiency*

Run Angio jet machine frequency*

IVUS *

IVUS proficiency*

IVUS frequency*

Biopsy *

Biopsy proficiency*

Biopsy frequency*

Call in Reports *

Call in Reports proficiency*

Call in Reports frequency*

DCAs *

DCAs proficiency*

DCAs frequency*

PTCAs *

PTCAs proficiency*

PTCAs frequency*

Left & Right Heart Cath *

Left & Right Heart Cath proficiency*

Left & Right Heart Cath frequency*

Hematoma Recognition & Mgt *

Hematoma Recognition & Mgt proficiency*

Hematoma Recognition & Mgt frequency*

Rotational Coronary Atherectomy *

Rotational Coronary Atherectomy proficiency*

Rotational Coronary Atherectomy frequency*

Intra Aortic Balloon Pump *

Intra Aortic Balloon Pump proficiency*

Intra Aortic Balloon Pump frequency*

EP study *

EP study proficiency*

EP study frequency*

Ablation *

Ablation proficiency*

Ablation frequency*

Cardioversion *

Cardioversion proficiency*

Cardioversion frequency*

Rotoblator *

Rotoblator proficiency*

Rotoblator frequency*

Cath Lab/Scrub

Proficiency Rating

Frequency Rating

Left Heart Catheterization *

Left Heart Catheterization proficiency*

Left Heart Catheterization frequency*

Right Heart Catheterization *

Right Heart Catheterization proficiency*

Right Heart Catheterization frequency*

Left and Right Heart Catheterization *

Left and Right Heart Catheterization proficiency*

Left and Right Heart Catheterization frequency*

IVUS *

IVUS proficiency*

IVUS frequency*

Temporary Pacemaker *

Temporary Pacemaker proficiency*

Temporary Pacemaker frequency*

Angio Jet *

Angio Jet proficiency*

Angio Jet frequency*

Cardioversion *

Cardioversion proficiency*

Cardioversion frequency*

Defibrillation *

Defibrillation proficiency*

Defibrillation frequency*

Intra Aortic Balloon Pump *

Intra Aortic Balloon Pump proficiency*

Intra Aortic Balloon Pump frequency*

SQICD *

SQICD proficiency*

SQICD frequency*

Micra *

Micra proficiency*

Micra frequency*

BIV PPM/ICD *

BIV PPM/ICD proficiency*

BIV PPM/ICD frequency*

Perm pacer *

Perm pacer proficiency*

Perm pacer frequency*

AICD Placement *

AICD Placement proficiency*

AICD Placement frequency*

Aortography *

Aortography proficiency*

Aortography frequency*

Cardiac Biopsy *

Cardiac Biopsy proficiency*

Cardiac Biopsy frequency*

Arterial Closure Devices *

Arterial Closure Devices proficiency*

Arterial Closure Devices frequency*

Cardiac Stent *

Cardiac Stent proficiency*

Cardiac Stent frequency*

Diagnostic Cardiac Catheterization Adult *

Diagnostic Cardiac Catheterization Adult proficiency*

Diagnostic Cardiac Catheterization Adult frequency*

Diagnostic Cardiac Catheterization - Neonatal/Pediatric *

Diagnostic Cardiac Catheterization - Neonatal/Pediatric proficiency*

Diagnostic Cardiac Catheterization - Neonatal/Pediatric frequency*

Directional Coronary Atherectomy *

Directional Coronary Atherectomy proficiency*

Directional Coronary Atherectomy frequency*

IABP Placement/Removal *

IABP Placement/Removal proficiency*

IABP Placement/Removal frequency*

Internal Mammary Angiography *

Internal Mammary Angiography proficiency*

Internal Mammary Angiography frequency*

Imaging Bypass Grafts *

Imaging Bypass Grafts proficiency*

Imaging Bypass Grafts frequency*

Laser assisted Procedures *

Laser assisted Procedures proficiency*

Laser assisted Procedures frequency*

Percutaneous Transluminal Coronary Angioplasty *

Percutaneous Transluminal Coronary Angioplasty proficiency*

Percutaneous Transluminal Coronary Angioplasty frequency*

Pericardiocentesis *

Pericardiocentesis proficiency*

Pericardiocentesis frequency*

Pulmonary Angiography *

Pulmonary Angiography proficiency*

Pulmonary Angiography frequency*

Rotational Coronary Atherectomy *

Rotational Coronary Atherectomy proficiency*

Rotational Coronary Atherectomy frequency*

Transluminal Extraction Catheter *

Transluminal Extraction Catheter proficiency*

Transluminal Extraction Catheter frequency*

Valvuloplasty *

Valvuloplasty proficiency*

Valvuloplasty frequency*

Venography *

Venography proficiency*

Venography frequency*

Ventricular Assist Device Insertion *

Ventricular Assist Device Insertion proficiency*

Ventricular Assist Device Insertion frequency*

Hemostasis Management *

Hemostasis Management proficiency*

Hemostasis Management frequency*

Vascular Closure Systems *

Vascular Closure Systems proficiency*

Vascular Closure Systems frequency*

External Compression Devices(Femostop, C-Clamp, Sandbags, etc) *

External Compression Devices(Femostop, C-Clamp, Sandbags, etc) proficiency*

External Compression Devices(Femostop, C-Clamp, Sandbags, etc) frequency*

Sheath Removal and Monitoring *

Sheath Removal and Monitoring proficiency*

Sheath Removal and Monitoring frequency*

Electrophysiology Evaluation *

Electrophysiology Evaluation proficiency*

Electrophysiology Evaluation frequency*

Baseline Measurements *

Baseline Measurements proficiency*

Baseline Measurements frequency*

Lithotripsy *

Cardiac Ablation proficiency*

Cardiac Ablation frequency*

Cardiac Mapping *

Cardiac Mapping proficiency*

Cardiac Mapping frequency*

Cardioversion *

Cardioversion proficiency*

Cardioversion frequency*

Conduction Study *

Conduction Study proficiency*

Conduction Study frequency*

Tilt Table Study *

Tilt Table Study proficiency*

Tilt Table Study frequency*

3D Mapping *

3D Mapping proficiency*

3D Mapping frequency*

Ablator *

Ablator proficiency*

Ablator frequency*

ICE *

ICE proficiency*

ICE frequency*

Pacing Protocols *

Pacing Protocols proficiency*

Pacing Protocols frequency*

Thermal Cool *

Thermal Cool proficiency*

Thermal Cool frequency*

Transseptal Procedures *

Transseptal Procedures proficiency*

Transseptal Procedures frequency*

Stroke Protocols (DVT) *

Stroke Protocols (DVT) proficiency*

Stroke Protocols (DVT) frequency*

Arterials (arms and legs) *

Arterials (arms and legs) proficiency*

Arterials (arms and legs) frequency*

Arrhythmias *

Arrhythmias proficiency*

Arrhythmias frequency*

Heart Block *

Heart Block proficiency*

Heart Block frequency*

Myocardial infarction *

Myocardial infarction proficiency*

Myocardial infarction frequency*

Pace Makers *

Pace Makers proficiency*

Pace Makers frequency*

Implantable Cardioverter Defibrillators *

Implantable Cardioverter Defibrillators proficiency*

Implantable Cardioverter Defibrillators frequency*

Electronic Medical Records

Proficiency Rating

Frequency Rating

Cerner *

Cerner proficiency*

Cerner frequency*

Eclipsys *

Eclipsys proficiency*

Eclipsys frequency*

Epic *

Epic proficiency*

Epic frequency*

GE *

GE proficiency*

GE frequency*

McKesson *

McKesson proficiency*

McKesson frequency*

MEDITECH *

MEDITECH proficiency*

MEDITECH frequency*

National Patient Safety Goals

Proficiency Rating

Frequency Rating

Universal Protocol Procedures *

Universal Protocol Procedures proficiency*

Universal Protocol Procedures frequency*

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Infection Prevention *

Infection Prevention proficiency*

Infection Prevention frequency*

Age Specific/Population Based Care *

Age Specific/Population Based Care proficiency*

Age Specific/Population Based Care frequency*

Fall Risk Assessment/Prevention *

Fall Risk Assessment/Prevention proficiency*

Fall Risk Assessment/Prevention frequency*

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Skills/Competences

Proficiency

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