Dialysis RN

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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*

GENERAL SKILLS

Proficiency Rating

Frequency Rating

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*

Crash Carts *

Crash Carts proficiency*

Crash Carts frequency*

Defibrillators *

Defibrillators proficiency*

Defibrillators frequency*

Care of Patient in Restraints *

Care of Patient in Restraints proficiency*

Care of Patient in Restraints frequency*

Pain Management *

Pain Management proficiency*

Pain Management frequency*

Automated Med Dispensing Systems *

Automated Med Dispensing Systems proficiency*

Automated Med Dispensing Systems frequency*

List Types:

Care Planning & Discharge Planning *

Care Planning & Discharge Planning proficiency*

Care Planning & Discharge Planning frequency*

Patient / Family Education *

Patient / Family Education proficiency*

Patient / Family Education frequency*

Electronic Documentation *

Electronic Documentation proficiency*

Electronic Documentation frequency*

List Types:

Peripheral IV Insertion, Care and Maintenance *

Peripheral IV Insertion, Care and Maintenance proficiency*

Peripheral IV Insertion, Care and Maintenance frequency*

Renal / Genitourinary

Proficiency Rating

Frequency Rating

Assessment of Renal / GU System *

Assessment of Renal / GU System proficiency*

Assessment of Renal / GU System frequency*

Insertion of urinary catheter (straight cath or foley) *

Insertion of urinary catheter (straight cath or foley) proficiency*

Insertion of urinary catheter (straight cath or foley) frequency*

Patient with Nephrostomy Tube *

Patient with Nephrostomy Tube proficiency*

Patient with Nephrostomy Tube frequency*

Patient with A V Fistula / A V Graft *

Patient with A V Fistula / A V Graft proficiency*

Patient with A V Fistula / A V Graft frequency*

Patient with Tunneled / Non - Tunneled Catheter *

Patient with Tunneled / Non - Tunneled Catheter proficiency*

Patient with Tunneled / Non - Tunneled Catheter frequency*

Patient with Ileal Conduit *

Patient with Ileal Conduit proficiency*

Patient with Ileal Conduit frequency*

Patient with Supra-Pubic Catheter *

Patient with Supra-Pubic Catheter proficiency*

Patient with Supra-Pubic Catheter frequency*

Patient with Renal Failure *

Patient with Renal Failure proficiency*

Patient with Renal Failure frequency*

Patient with Nephrectomy *

Patient with Nephrectomy proficiency*

Patient with Nephrectomy frequency*

Patient with TURP *

Patient with TURP proficiency*

Patient with TURP frequency*

Patient on Peritoneal Dialysis *

Patient on Peritoneal Dialysis proficiency*

Patient on Peritoneal Dialysis frequency*

Patient on Hemodialysis *

Patient on Hemodialysis proficiency*

Patient on Hemodialysis frequency*

Hemodialysis Skills / Procedures Experience

Proficiency Rating

Frequency Rating

Acute / Inpatient Dialysis *

Acute / Inpatient Dialysis proficiency*

Acute / Inpatient Dialysis frequency*

Chronic / Outpatient Dialysis *

Chronic / Outpatient Dialysis proficiency*

Chronic / Outpatient Dialysis frequency*

Dialysis Home Care *

Dialysis Home Care proficiency*

Dialysis Home Care frequency*

Pediatric Dialysis *

Pediatric Dialysis proficiency*

Pediatric Dialysis frequency*

Predialysis Nursing Assessment *

Predialysis Nursing Assessment proficiency*

Predialysis Nursing Assessment frequency*

Set Up / Initiate Dialysis Treatment

Proficiency Rating

Frequency Rating

Bicarbonate Dialysate *

Bicarbonate Dialysate proficiency*

Bicarbonate Dialysate frequency*

Conductivity Testing *

Conductivity Testing proficiency*

Conductivity Testing frequency*

Priming Dialyzer *

Priming Dialyzer proficiency*

Priming Dialyzer frequency*

Checks for Machine / Alarm Settings *

Checks for Machine / Alarm Settings proficiency*

Checks for Machine / Alarm Settings frequency*

Prep Vascular Access *

Prep Vascular Access proficiency*

Prep Vascular Access frequency*

Fistula Gortex / Bovine Graft *

Fistula Gortex / Bovine Graft proficiency*

Fistula Gortex / Bovine Graft frequency*

Dialysis *

Dialysis proficiency*

Dialysis frequency*

Collect Blood Specimens *

Collect Blood Specimens proficiency*

Collect Blood Specimens frequency*

Volume Status *

Volume Status proficiency*

Volume Status frequency*

Vascular Access Function *

Vascular Access Function proficiency*

Vascular Access Function frequency*

Arterial and Venous Pressures *

Arterial and Venous Pressures proficiency*

Arterial and Venous Pressures frequency*

Blood Flow Rate *

Blood Flow Rate proficiency*

Blood Flow Rate frequency*

Subjective Response to Treatment *

Subjective Response to Treatment proficiency*

Subjective Response to Treatment frequency*

Management of Anticoagulation *

Management of Anticoagulation proficiency*

Management of Anticoagulation frequency*

Conductivity *

Conductivity proficiency*

Conductivity frequency*

Ultrafiltration Calculation *

Ultrafiltration Calculation proficiency*

Ultrafiltration Calculation frequency*

Myron L. Water Meter *

Myron L. Water Meter proficiency*

Myron L. Water Meter frequency*

Administration of Mannitol *

Administration of Mannitol proficiency*

Administration of Mannitol frequency*

Sequential Ultrafiltration / PUF *

Sequential Ultrafiltration / PUF proficiency*

Sequential Ultrafiltration / PUF frequency*

Documentation of Dialysis Treatment *

Documentation of Dialysis Treatment proficiency*

Documentation of Dialysis Treatment frequency*

Fluid Overload *

Fluid Overload proficiency*

Fluid Overload frequency*

Hypertension *

Hypertension proficiency*

Hypertension frequency*

Hypotension *

Hypotension proficiency*

Hypotension frequency*

Disequilibrium Syndrome *

Disequilibrium Syndrome proficiency*

Disequilibrium Syndrome frequency*

Hyperkalemia *

Hyperkalemia proficiency*

Hyperkalemia frequency*

Seizures *

Seizures proficiency*

Seizures frequency*

Muscle Cramps *

Muscle Cramps proficiency*

Muscle Cramps frequency*

Clotted Access / Poor Blood Flow Rate from Catheter *

Clotted Access / Poor Blood Flow Rate from Catheter proficiency*

Clotted Access / Poor Blood Flow Rate from Catheter frequency*

Pyrogenic Reaction *

Pyrogenic Reaction proficiency*

Pyrogenic Reaction frequency*

Hemolysis *

Hemolysis proficiency*

Hemolysis frequency*

Air Embolus *

Air Embolus proficiency*

Air Embolus frequency*

Chest Pain *

Chest Pain proficiency*

Chest Pain frequency*

Anemia *

Anemia proficiency*

Anemia frequency*

Neuropathy *

Neuropathy proficiency*

Neuropathy frequency*

Pericarditis *

Pericarditis proficiency*

Pericarditis frequency*

Filter Blood Leak *

Filter Blood Leak proficiency*

Filter Blood Leak frequency*

Alarm

Proficiency Rating

Frequency Rating

Blood Leak Alarm *

Blood Leak Alarm proficiency*

Blood Leak Alarm frequency*

Arterial Pressure Alarm *

Arterial Pressure Alarm proficiency*

Arterial Pressure Alarm frequency*

Venous Pressure Alarm *

Venous Pressure Alarm proficiency*

Venous Pressure Alarm frequency*

Conductivity Alarm *

Conductivity Alarm proficiency*

Conductivity Alarm frequency*

Ultrafiltration Alarm *

Ultrafiltration Alarm proficiency*

Ultrafiltration Alarm frequency*

High Temperature Alarm *

High Temperature Alarm proficiency*

High Temperature Alarm frequency*

Air / Foam Detector Alarm *

Air / Foam Detector Alarm proficiency*

Air / Foam Detector Alarm frequency*

Power Failure Alarm *

Power Failure Alarm proficiency*

Power Failure Alarm frequency*

Blood Pump Alarm *

Blood Pump Alarm proficiency*

Blood Pump Alarm frequency*

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Date*

Skills/Competences

Proficiency

Frequency

DIALYSIS RN

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