Interventional Skills

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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*

Work Settings

Proficiency Rating

Frequency Rating

Interventional Lab *

Interventional Lab proficiency*

Interventional 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*

Level II Trauma *

Level II Trauma proficiency*

Level II Trauma frequency*

Special Procedures

Proficiency Rating

Frequency Rating

Scrub Technologist *

Scrub Technologist proficiency*

Scrub Technologist frequency*

Monitor Technologist *

Monitor Technologist proficiency*

Monitor Technologist frequency*

Circulation Technologist *

Circulation Technologist proficiency*

Circulation Technologist frequency*

Panning *

Panning proficiency*

Panning frequency*

Arch Aortagram *

Arch Aortagram proficiency*

Arch Aortagram frequency*

Abdominal Aortagram *

Abdominal Aortagram proficiency*

Abdominal Aortagram frequency*

Renal Aortagram *

Renal Aortagram proficiency*

Renal Aortagram frequency*

Pulmonary Arteriogram *

Pulmonary Arteriogram proficiency*

Pulmonary Arteriogram frequency*

Atherectomies *

Atherectomies proficiency*

Atherectomies frequency*

Selective Angiography *

Selective Angiography proficiency*

Selective Angiography frequency*

Mechanical Thrombectomy *

Mechanical Thrombectomy proficiency*

Mechanical Thrombectomy frequency*

Thrombolysis *

Thrombolysis proficiency*

Thrombolysis frequency*

AVM/AVF Intervention *

AVM/AVF Intervention proficiency*

AVM/AVF Intervention frequency*

Drainage Catheter insertion *

Drainage Catheter insertion proficiency*

Drainage Catheter insertion frequency*

TIPS - Transjugular Portosystemic Shunt *

TIPS - Transjugular Portosystemic Shunt proficiency*

TIPS - Transjugular Portosystemic Shunt frequency*

Fistulogram *

Fistulogram proficiency*

Fistulogram frequency*

Declot *

Declot proficiency*

Declot frequency*

IVC Filter Insertion *

IVC Filter Insertion proficiency*

IVC Filter Insertion frequency*

Biopsy Assist Kyphoplasty/Vertebral *

Biopsy Assist Kyphoplasty/Vertebral proficiency*

Biopsy Assist Kyphoplasty/Vertebral frequency*

Endo Vascular *

Endo Vascular proficiency*

Endo Vascular frequency*

Equipment

Proficiency Rating

Frequency Rating

Lithotripsy *

Rotational Arthrectomy proficiency*

Rotational Arthrectomy frequency*

Directional Arthrectomy *

Directional Arthrectomy proficiency*

Directional Arthrectomy frequency*

Angiojet *

Angiojet proficiency*

Angiojet frequency*

Ekos *

Ekos proficiency*

Ekos frequency*

GE *

GE proficiency*

GE frequency*

Siemens *

Siemens proficiency*

Siemens frequency*

Philips *

Philips proficiency*

Philips frequency*

MacLab *

MacLab proficiency*

MacLab frequency*

Automatic Injector *

Automatic Injector proficiency*

Automatic Injector frequency*

Proficiency Rating

Frequency Rating

Rotational Arthrectomy *

Rotational Arthrectomy proficiency*

Rotational Arthrectomy frequency*

Directional Arthrectomy *

Directional Arthrectomy proficiency*

Directional Arthrectomy frequency*

Lower Extremity Arteriograms *

Lower Extremity Arteriograms proficiency*

Lower Extremity Arteriograms frequency*

Lower Extremity Venograms *

Lower Extremity Venograms proficiency*

Lower Extremity Venograms frequency*

Upper Extremity Arteriograms *

Upper Extremity Arteriograms proficiency*

Upper Extremity Arteriograms frequency*

Upper Extremity Venograms *

Upper Extremity Venograms proficiency*

Upper Extremity Venograms frequency*

Chemo Embo *

Chemo Embo proficiency*

Chemo Embo frequency*

Bland Vascular Embo *

Bland Vascular Embo proficiency*

Bland Vascular Embo frequency*

Y-90 (Radio Embo) *

Y-90 (Radio Embo) proficiency*

Y-90 (Radio Embo) frequency*

Trauma *

Trauma proficiency*

Trauma frequency*

GI Bleed *

GI Bleed proficiency*

GI Bleed frequency*

Cryo Ablation *

Cryo Ablation proficiency*

Cryo Ablation frequency*

RF Ablation *

RF Ablation proficiency*

RF Ablation frequency*

Microwave Ablation *

Microwave Ablation proficiency*

Microwave Ablation frequency*

Laser Assisted Procedures *

Laser Assisted Procedures proficiency*

Laser Assisted Procedures frequency*

Neuro

Proficiency Rating

Frequency Rating

Intracranial Bleed *

Intracranial Bleed proficiency*

Intracranial Bleed frequency*

Penumbra *

Penumbra proficiency*

Penumbra frequency*

Carotid Arteriogram *

Carotid Arteriogram proficiency*

Carotid Arteriogram frequency*

Carotid Stenting *

Carotid Stenting proficiency*

Carotid Stenting frequency*

Intracranial Aneurysm repair/coiling *

Intracranial Aneurysm repair/coiling proficiency*

Intracranial Aneurysm repair/coiling 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

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*

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Date*

Skills/Competences

Proficiency

Frequency

INTERVENTIONAL SKILLS

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