Name*
First
Last
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* Automated Med Dispensing Systems *
Automated Med Dispensing Systems proficiency* Automated Med Dispensing Systems frequency* Care Planning & Discharge Planning *
Care Planning & Discharge Planning proficiency* Care Planning & Discharge Planning frequency* Participation on Code Teams *
Participation on Code Teams proficiency* Participation on Code Teams frequency* Patient / Family Education *
Patient / Family Education proficiency* Patient / Family Education frequency* Electronic Documentation *
Electronic Documentation proficiency* Electronic Documentation frequency* Access / Management of Implanted Ports *
Access / Management of Implanted Ports proficiency* Access / Management of Implanted Ports frequency* Access / Management of Central Lines *
Access / Management of Central Linesproficiency* Access / Management of Central Lines frequency* Titration of Drips *
Titration of Drips proficiency* Titration of Drips frequency* Administration of Blood / Blood Products *
Administration of Blood / Blood Products proficiency* Administration of Blood / Blood Products frequency* Knowledge of Current IV Therapy Guidelines *
Knowledge of Current IV Therapy Guidelines proficiency* Knowledge of Current IV Therapy Guidelines frequency* Knowledge of Anatomy *
Knowledge of Anatomy proficiency* Knowledge of Anatomy frequency* Moderate Conscious Sedation *
Moderate Conscious Sedation proficiency* Moderate Conscious Sedation frequency* Sedation Reversal Agents *
Sedation Reversal Agents proficiency* Sedation Reversal Agents frequency*
Knowledge of Current IV Therapy Guidelines
Proficiency Rating
Frequency Rating
INS *
INS proficiency* INS frequency* ISMP *
ISMP proficiency* ISMP frequency* CDC *
CDC proficiency* CDC frequency* State *
State proficiency* State frequency*
Insertion of:
Proficiency Rating
Frequency Rating
Peripheral IV – Adult *
Peripheral IV – Adult proficiency* Peripheral IV – Adult frequency* Peripheral IV – Child *
Peripheral IV – Child proficiency* Peripheral IV – Child frequency* Peripheral IV – Neonate *
Peripheral IV – Neonate proficiency* Peripheral IV – Neonate frequency* Vein Selection – Peripheral IVs *
Vein Selection – Peripheral IVs proficiency* Vein Selection – Peripheral IVs frequency* Interosseous Needles *
Interosseous Needles proficiency* Interosseous Needles frequency*
Midline / PICC Lines
Proficiency Rating
Frequency Rating
Midline Catheter Insertion – Adult *
Midline Catheter Insertion – Adult proficiency* Midline Catheter Insertion – Adult frequency* Midline Catheter Insertion – Child *
Midline Catheter Insertion – Child proficiency* Midline Catheter Insertion – Child frequency* Indications for Midline / PICC Placement *
Indications for Midline / PICC Placement proficiency* Indications for Midline / PICC Placement frequency* Contraindications for Midline / PICC Placement *
Contraindications for Midline / PICC Placement proficiency* Contraindications for Midline / PICC Placement frequency* Vein Selection *
Vein Selection proficiency* Vein Selection frequency* Measuring Technique *
Measuring Technique proficiency* Measuring Technique frequency* Catheter and Introducer Device Selection *
Catheter and Introducer Device Selection proficiency* Catheter and Introducer Device Selection frequency* Correct Tip Placement *
Correct Tip Placement proficiency* Correct Tip Placement frequency* Insertion Technique – Basic (Vein) *
Insertion Technique – Basic (Vein) proficiency* Insertion Technique – Basic (Vein) frequency* Insertion Technique – Seldinger *
Insertion Technique – Seldinger proficiency* Insertion Technique – Seldinger frequency* Insertion Technique – Ultrasound *
Insertion Technique – Ultrasound proficiency* Insertion Technique – Ultrasound frequency* *
Assist with Insertion in Interventional Radiology proficiency* Assist with Insertion in Interventional Radiology frequency* Insertion Site Preparation *
Insertion Site Preparation proficiency* Insertion Site Preparation frequency* Maintaining Sterile Field *
Maintaining Sterile Field proficiency* Maintaining Sterile Field frequency* Securing Insertion Site Post Placement *
Securing Insertion Site Post Placement proficiency* Securing Insertion Site Post Placement frequency* X-Ray Assessment for Tip Location *
X-Ray Assessment for Tip Location proficiency* X-Ray Assessment for Tip Location frequency* Repositioning After X-Ray *
Repositioning After X-Ray proficiency* Repositioning After X-Ray frequency*
Care & Maintenance
Proficiency Rating
Frequency Rating
Peripheral IV *
Peripheral IV proficiency* Peripheral IV frequency* Scalp IV *
Scalp IV proficiency* Scalp IV frequency* Heparin / Saline Lock *
Heparin / Saline Lock proficiency* Heparin / Saline Lock frequency* Groshong PICC *
Groshong PICC proficiency* Groshong PICC frequency* Groshong CVL *
Groshong CVL proficiency* Groshong CVL frequency* Hickman / Broviac *
Hickman / Broviac proficiency* Hickman / Broviac frequency* Port-a-Cath *
Port-a-Cath proficiency* Port-a-Cath frequency* Vascath *
Vascath proficiency* Vascath frequency* Multilumen Catheters *
Multilumen Catheters proficiency* Multilumen Catheters frequency* Subclavian Line *
Subclavian Line proficiency* Subclavian Line frequency* IJ Line *
IJ Line proficiency* IJ Line frequency* Femoral Line *
Femoral Line proficiency* Femoral Line frequency* Power PICC *
Power PICC proficiency* Power PICC frequency* Power Port *
Power Port proficiency* Power Port frequency* Cap Changes *
Cap Changes proficiency* Cap Changes frequency* Flushing Lines (Frequency / Solution) *
Flushing Lines (Frequency / Solution) proficiency* Flushing Lines (Frequency / Solution) frequency*
Medication Administration
Proficiency Rating
Frequency Rating
Chemotherapy *
Chemotherapy proficiency* Chemotherapy frequency* Heparin *
Heparin proficiency* Heparin frequency* Streptokinase *
Streptokinase proficiency* Streptokinase frequency* TPA (Alteplase) *
TPA (Alteplase) proficiency* TPA (Alteplase) frequency* Lidocaine *
Lidocaine proficiency* Lidocaine frequency* TPN / Lipids *
TPN / Lipids proficiency* TPN / Lipids frequency* Ativan *
Ativan proficiency* Ativan frequency* Valium *
Valium proficiency* Valium frequency* Versed *
Versed proficiency* Versed frequency* Fentanyl *
Fentanyl proficiency* Fentanyl frequency*
Equipment
Proficiency Rating
Frequency Rating
Curlin Pump *
Curlin Pump proficiency* Curlin Pump frequency* CADD Pump *
CADD Pump proficiency* CADD Pump frequency* Vista Pump *
Vista Pump proficiency* Vista Pump frequency* Syringe Pump *
Syringe Pump proficiency* Syringe Pump frequency* Rate Flow Regulator *
Rate Flow Regulator proficiency* Rate Flow Regulator frequency* Needleless Systems *
Needleless Systems proficiency* Needleless Systems frequency* Blood Warmer *
Blood Warmer proficiency* Blood Warmer frequency* PCA Pumps *
PCA Pumps proficiency* PCA Pumps frequency* Pressure Lines *
Pressure Lines proficiency* Pressure Lines frequency*
Troubleshooting / Complications
Proficiency Rating
Frequency Rating
Repair PICC *
Repair PICC proficiency* Repair PICC frequency* Repair Midline *
Repair Midline proficiency* Repair Midline frequency* Air Embolism *
Air Embolism proficiency* Air Embolism frequency* Bleeding *
Bleeding proficiency* Bleeding frequency* Brachial Plexus Injury *
Brachial Plexus Injury proficiency* Brachial Plexus Injury frequency* Cardiac Arrhythmia *
Cardiac Arrhythmia proficiency* Cardiac Arrhythmia frequency* Cardiac Tamponade *
Cardiac Tamponade proficiency* Cardiac Tamponade frequency* Catheter Erosion *
Catheter Erosion proficiency* Catheter Erosion frequency* Catheter Embolism *
Catheter Embolism proficiency* Catheter Embolism frequency* Catheter Occlusion *
Catheter Occlusion proficiency* Catheter Occlusion frequency* Catheter - Related Sepsis *
Catheter - Related Sepsis proficiency* Catheter - Related Sepsis frequency* Endocarditis *
Endocarditis proficiency* Endocarditis frequency* Exit Site Infection *
Exit Site Infection proficiency* Exit Site Infection frequency* Exit Site Necrosis *
Exit Site Necrosis proficiency* Exit Site Necrosis frequency* Extravasation *
Extravasation proficiency* Extravasation frequency* Hematoma *
Hematoma proficiency* Hematoma frequency* Laceration of Vessels or Viscus *
Laceration of Vessels or Viscus proficiency* Laceration of Vessels or Viscus frequency* Myocardial Erosion *
Myocardial Erosion proficiency* Myocardial Erosion frequency* Perforation of Vessels or Viscus *
Perforation of Vessels or Viscus proficiency* Perforation of Vessels or Viscus frequency* Phlebitis *
Phlebitis proficiency* Phlebitis frequency* Catheter Tip Malposition or Retraction *
Catheter Tip Malposition or Retraction proficiency* Catheter Tip Malposition or Retraction frequency* Thromboembolism *
Thromboembolism proficiency* Thromboembolism frequency* Venous Thrombosis *
Venous Thrombosis proficiency* Venous Thrombosis frequency* Ventricular Thrombosis *
Ventricular Thrombosis proficiency* Ventricular Thrombosis frequency* Vessel Erosion *
Vessel Erosion proficiency* Vessel Erosion frequency* Declotting Peripheral Site *
Declotting Peripheral Site proficiency* Declotting Peripheral Site frequency* Complications from Sedation *
Complications from Sedation proficiency* Complications from Sedation frequency*
Discontinuing IV Therapy
Proficiency Rating
Frequency Rating
Peripheral IVs *
Peripheral IVs proficiency* Peripheral IVs frequency* PICC / Midline *
PICC / Midline proficiency* PICC / Midline frequency* Central Lines *
Central Lines proficiency* Central Lines frequency* Other Skills *
Other Skills proficiency* Other Skills frequency* Certify your information* I certify that I have provided true and accurate information about my skills and experience to the best of my ability
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