PACU

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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*

General Skills

Proficiency Rating

Frequency Rating

Standard Precautions *

Standard Precautions proficiency*

Standard Precautions frequency*

Isolation Precautions *

Isolation Precautions proficiency*

Isolation Precautions frequency*

Patient Head to Toe Assessment *

Patient Head to Toe Assessment proficiency*

Patient Head to Toe Assessment frequency*

Medication Titration *

Medication Titration proficiency*

Medication Titration 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*

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:

Document Interventions, Outcomes, Lab Studies, MD Notifications & Follow - up Care *

Document Interventions, Outcomes, Lab Studies, MD Notifications & Follow - up Care proficiency*

Document Interventions, Outcomes, Lab Studies, MD Notifications & Follow - up Care frequency*

Admission To PACU

Proficiency Rating

Frequency Rating

Initial Assessment / Vital Signs *

Initial Assessment / Vital Signs proficiency*

Initial Assessment / Vital Signs frequency*

Airway Management *

Airway Management proficiency*

Airway Management frequency*

Proper Positioning *

Proper Positioning proficiency*

Proper Positioning frequency*

Skin Color, Temp, Turgor *

Skin Color, Temp, Turgor proficiency*

Skin Color, Temp, Turgor frequency*

Neurological Status *

Neurological Status proficiency*

Neurological Status frequency*

Monitor Recovery of Patient From:

Proficiency Rating

Frequency Rating

General Anesthesia *

General Anesthesia proficiency*

General Anesthesia frequency*

Regional Anesthesia *

Regional Anesthesia proficiency*

Regional Anesthesia frequency*

Local Anesthesia *

Local Anesthesia proficiency*

Local Anesthesia frequency*

Neuro Skills

Proficiency Rating

Frequency Rating

Neuro Assessment *

Neuro Assessment proficiency*

Neuro Assessment frequency*

Glasgow Coma Scale *

Glasgow Coma Scale proficiency*

Glasgow Coma Scale frequency*

Neuro Skills - Care of the Post Operative Patient with:

Proficiency Rating

Frequency Rating

Spinal Fusion *

Spinal Fusion proficiency*

Spinal Fusion frequency*

Spinal Cord Injury *

Spinal Cord Injury proficiency*

Spinal Cord Injury frequency*

Ventriculostomy *

Ventriculostomy proficiency*

Ventriculostomy frequency*

Craniotomy *

Craniotomy proficiency*

Craniotomy frequency*

ICP Monitor *

ICP Monitor proficiency*

ICP Monitor frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Sedatives *

Sedatives proficiency*

Sedatives frequency*

Barbiturates *

Barbiturates proficiency*

Barbiturates frequency*

Cardiac Skills

Proficiency Rating

Frequency Rating

Use of Doppler *

Use of Doppler proficiency*

Use of Doppler frequency*

Cardiac Assessment (Auscultation) *

Cardiac Assessment (Auscultation) proficiency*

Cardiac Assessment (Auscultation) frequency*

Knowledge of Labs and Normal Values *

Knowledge of Labs and Normal Values proficiency*

Knowledge of Labs and Normal Values frequency*

12 Lead Interpretation *

12 Lead Interpretation proficiency*

12 Lead Interpretation frequency*

Arrhythmia Analysis *

Arrhythmia Analysis proficiency*

Arrhythmia Analysis frequency*

Cardioversion & Defibrillation *

Cardioversion & Defibrillation proficiency*

Cardioversion & Defibrillation frequency*

Assist with Insertion of Temporary Pacemaker *

Assist with Insertion of Temporary Pacemaker proficiency*

Assist with Insertion of Temporary Pacemaker frequency*

Use of Non - Invasive Temporary Pacing Equipment *

Use of Non - Invasive Temporary Pacing Equipment proficiency*

Use of Non - Invasive Temporary Pacing Equipment frequency*

Intravascular Hemodynamic Monitoring:

Proficiency Rating

Frequency Rating

Pulmonary Artery Catheters *

Pulmonary Artery Catheters proficiency*

Pulmonary Artery Catheters frequency*

Arterial Catheters *

Arterial Catheters proficiency*

Arterial Catheters frequency*

Swan - Ganz Catheters *

Swan - Ganz Catheters proficiency*

Swan - Ganz Catheters frequency*

Equipment Maintenance *

Equipment Maintenance proficiency*

Equipment Maintenance frequency*

Dressing Changes *

Dressing Changes proficiency*

Dressing Changes frequency*

Prevention of Complications *

Prevention of Complications proficiency*

Prevention of Complications frequency*

Leveling Waveform Analysis *

Leveling Waveform Analysis proficiency*

Leveling Waveform Analysis frequency*

Obtain and Interpret:

Proficiency Rating

Frequency Rating

Cardiac Output *

Cardiac Output proficiency*

Cardiac Output frequency*

PA Pressure *

PA Pressure proficiency*

PA Pressure frequency*

PCWP / PAWP *

PCWP / PAWP proficiency*

PCWP / PAWP frequency*

CVP *

CVP proficiency*

CVP frequency*

LAP *

LAP proficiency*

LAP frequency*

Cardiac - Care of the Post Operative Patient with:

Proficiency Rating

Frequency Rating

Malignant Hyperthermia *

Malignant Hyperthermia proficiency*

Malignant Hyperthermia frequency*

AAA Repair *

AAA Repair proficiency*

AAA Repair frequency*

Open Heart Surgery (CABG) *

Open Heart Surgery (CABG) proficiency*

Open Heart Surgery (CABG) frequency*

Off Pump Heart Surgery *

Off Pump Heart Surgery proficiency*

Off Pump Heart Surgery frequency*

Valve Repair *

Valve Repair proficiency*

Valve Repair frequency*

Permanent / Temporary Pacemaker *

Permanent / Temporary Pacemaker proficiency*

Permanent / Temporary Pacemaker frequency*

Congestive Heart Failure *

Congestive Heart Failure proficiency*

Congestive Heart Failure frequency*

Heart Transplant *

Heart Transplant proficiency*

Heart Transplant frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Antiarrhythmics *

Antiarrhythmics proficiency*

Antiarrhythmics frequency*

Calcium Channel Blockers *

Calcium Channel Blockers proficiency*

Calcium Channel Blockers frequency*

Beta Blockers *

Beta Blockers proficiency*

Beta Blockers frequency*

Heparin *

Heparin proficiency*

Heparin frequency*

Dopamine *

Dopamine proficiency*

Dopamine frequency*

Dobutamine *

Dobutamine proficiency*

Dobutamine frequency*

Proficiency Rating

Frequency Rating

Airway Insertion / Management *

Airway Insertion / Management proficiency*

Airway Insertion / Management frequency*

Assess Respiratory Rate, Rhythm, Depth & Symmetry *

Assess Respiratory Rate, Rhythm, Depth & Symmetry proficiency*

Assess Respiratory Rate, Rhythm, Depth & Symmetry frequency*

Auscultate Breath Sounds *

Auscultate Breath Sounds proficiency*

Auscultate Breath Sounds frequency*

Recognize Abnormal Breath Sounds (e.g. rales, rhonchi) & Implement Interventions *

Recognize Abnormal Breath Sounds (e.g. rales, rhonchi) & Implement Interventions proficiency*

Recognize Abnormal Breath Sounds (e.g. rales, rhonchi) & Implement Interventions frequency*

Laryngospasm *

Laryngospasm proficiency*

Laryngospasm frequency*

Obtain ABGs *

Obtain ABGs proficiency*

Obtain ABGs frequency*

Knowledge of ABGs and Normal Values *

Knowledge of ABGs and Normal Values proficiency*

Knowledge of ABGs and Normal Values frequency*

Set - up Chest Tube Drainage System *

Set - up Chest Tube Drainage System proficiency*

Set - up Chest Tube Drainage System frequency*

Recognize Air Leak, Assess for SQ Emphysema *

Recognize Air Leak, Assess for SQ Emphysema proficiency*

Recognize Air Leak, Assess for SQ Emphysema frequency*

Measure Drainage *

Measure Drainage proficiency*

Measure Drainage frequency*

Perform Suctioning:

Proficiency Rating

Frequency Rating

Oral *

Oral proficiency*

Oral frequency*

Nasal *

Nasal proficiency*

Nasal frequency*

Endotracheal *

Endotracheal proficiency*

Endotracheal frequency*

Tracheal *

Tracheal proficiency*

Tracheal frequency*

02 Administration:

Proficiency Rating

Frequency Rating

Mask *

Mask proficiency*

Mask frequency*

Nasal Cannula *

Nasal Cannula proficiency*

Nasal Cannula frequency*

T - Piece *

T - Piece proficiency*

T - Piece frequency*

ETT Mechanical Ventilator *

ETT Mechanical Ventilator proficiency*

ETT Mechanical Ventilator frequency*

Respiratory - Care of the Post Operative Patient with:

Proficiency Rating

Frequency Rating

Pneumothorax *

Pneumothorax proficiency*

Pneumothorax frequency*

Chest Tube *

Chest Tube proficiency*

Chest Tube frequency*

Lung Transplant *

Lung Transplant proficiency*

Lung Transplant frequency*

Thoracotomy *

Thoracotomy proficiency*

Thoracotomy frequency*

Lobectomy *

Lobectomy proficiency*

Lobectomy frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Bronchodilators *

Bronchodilators proficiency*

Bronchodilators frequency*

Diuretics *

Diuretics proficiency*

Diuretics frequency*

Corticosteroids *

Corticosteroids proficiency*

Corticosteroids frequency*

Racemic Epinephrine *

Racemic Epinephrine proficiency*

Racemic Epinephrine frequency*

Gastrointestinal Skills

Proficiency Rating

Frequency Rating

Bowel Sounds / Abdominal Assessment *

Bowel Sounds / Abdominal Assessment proficiency*

Bowel Sounds / Abdominal Assessment frequency*

G or J Tube *

G or J Tube proficiency*

G or J Tube frequency*

NG Tubes *

NG Tubes proficiency*

NG Tubes frequency*

Ostomy Care and Assessment *

Ostomy Care and Assessment proficiency*

Ostomy Care and Assessment frequency*

Gastrointestinal - Care of the Post Operative Patient with:

Proficiency Rating

Frequency Rating

Gastric Bypass *

Gastric Bypass proficiency*

Gastric Bypass frequency*

Appendectomy *

Appendectomy proficiency*

Appendectomy frequency*

Colostomy / Ileostomy *

Colostomy / Ileostomy proficiency*

Colostomy / Ileostomy frequency*

GI Surgery *

GI Surgery proficiency*

GI Surgery frequency*

Liver Transplant *

Liver Transplant proficiency*

Liver Transplant frequency*

Small Bowel Transplant *

Small Bowel Transplant proficiency*

Small Bowel Transplant frequency*

Pancreatic Transplant *

Pancreatic Transplant proficiency*

Pancreatic Transplant frequency*

ERCP *

ERCP proficiency*

ERCP frequency*

Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Antiemetics *

Antiemetics proficiency*

Antiemetics frequency*

Lipids / TPN / PPN *

Lipids / TPN / PPN proficiency*

Lipids / TPN / PPN frequency*

GU / Renal Skills

Proficiency Rating

Frequency Rating

Assessment of Output *

Assessment of Output proficiency*

Assessment of Output frequency*

Catheters *

Catheters proficiency*

Catheters frequency*

Urethral *

Urethral proficiency*

Urethral frequency*

Suprapubic *

Suprapubic proficiency*

Suprapubic frequency*

Bladder Irrigation *

Bladder Irrigation proficiency*

Bladder Irrigation frequency*

Knowledge of Normal Lab Chemistry Values *

Knowledge of Normal Lab Chemistry Values proficiency*

Knowledge of Normal Lab Chemistry Values frequency*

GU / Renal Skills - Care of the Post Operative Patient with:

Proficiency Rating

Frequency Rating

Shunts / Fistulas *

Shunts / Fistulas proficiency*

Shunts / Fistulas frequency*

TURB *

TURB proficiency*

TURB frequency*

Nephrectomy *

Nephrectomy proficiency*

Nephrectomy frequency*

Kidney Transplant *

Kidney Transplant proficiency*

Kidney Transplant frequency*

Bladder Repair *

Bladder Repair proficiency*

Bladder Repair frequency*

Testicular Procedures *

Testicular Procedures proficiency*

Testicular Procedures frequency*

Lithotripsy (ESWL) *

Lithotripsy (ESWL) proficiency*

Lithotripsy (ESWL) frequency*

Orthopedic Skills

Proficiency Rating

Frequency Rating

Circulation / Movement / Sensation Checks *

Circulation / Movement / Sensation Checks proficiency*

Circulation / Movement / Sensation Checks frequency*

Cold Systems *

Cold Systems proficiency*

Cold Systems frequency*

Braces / Casts *

Braces / Casts proficiency*

Braces / Casts frequency*

Orthopedic - Care of Post Operative Patient with:

Proficiency Rating

Frequency Rating

Amputation *

Amputation proficiency*

Amputation frequency*

Total Joint *

Total Joint proficiency*

Total Joint frequency*

Fractures *

Fractures proficiency*

Fractures frequency*

Arthroscopic Procedures *

Arthroscopic Procedures proficiency*

Arthroscopic Procedures frequency*

Eye / Ear - Care of Post - Operative Patient with:

Proficiency Rating

Frequency Rating

Cataract Extraction *

Cataract Extraction proficiency*

Cataract Extraction frequency*

Keratoplasty (Corneal Transplant) *

Keratoplasty (Corneal Transplant) proficiency*

Keratoplasty (Corneal Transplant) frequency*

Laser Eye Surgery *

Laser Eye Surgery proficiency*

Laser Eye Surgery frequency*

Orbital Fracture *

Orbital Fracture proficiency*

Orbital Fracture frequency*

Orbital Implant *

Orbital Implant proficiency*

Orbital Implant frequency*

Scleral Bucking (for Retinal Detachment) *

Scleral Bucking (for Retinal Detachment) proficiency*

Scleral Bucking (for Retinal Detachment) frequency*

Dacryocystectomy *

Dacryocystectomy proficiency*

Dacryocystectomy frequency*

Myringotomy *

Myringotomy proficiency*

Myringotomy frequency*

Cochlear Implant *

Cochlear Implant proficiency*

Cochlear Implant frequency*

Pain Management

Proficiency Rating

Frequency Rating

Assessment and Documentation of Pain and Follow Up After Intervention *

Assessment and Documentation of Pain and Follow Up After Intervention proficiency*

Assessment and Documentation of Pain and Follow Up After Intervention frequency*

PCA Systems *

PCA Systems proficiency*

PCA Systems frequency*

Epidural Pain Systems *

Epidural Pain Systems proficiency*

Epidural Pain Systems frequency*

Knowledge and Use of

Proficiency Rating

Frequency Rating

IV Sedation *

IV Sedation proficiency*

IV Sedation frequency*

Titration of Medication Per Orders *

Titration of Medication Per Orders proficiency*

Titration of Medication Per Orders frequency*

Narcotic Analgesic *

Narcotic Analgesic proficiency*

Narcotic Analgesic frequency*

Non - Narcotic Analgesics *

Non - Narcotic Analgesics proficiency*

Non - Narcotic Analgesics frequency*

Muscle Relaxants *

Muscle Relaxants proficiency*

Muscle Relaxants frequency*

Additional Medications Knowledge and Use of

Proficiency Rating

Frequency Rating

Calculate Infusion Rates in Dosages Ordered *

Calculate Infusion Rates in Dosages Ordered proficiency*

Calculate Infusion Rates in Dosages Ordered frequency*

Ionotropes *

Ionotropes proficiency*

Ionotropes frequency*

Vasopressors *

Vasopressors proficiency*

Vasopressors frequency*

Vasodilators *

Vasodilators proficiency*

Vasodilators frequency*

Reversal Agents *

Reversal Agents proficiency*

Reversal Agents frequency*

IV therapy / Phlebotomy

Proficiency Rating

Frequency Rating

Peripheral IV Insertion, Care and Maintenance *

Peripheral IV Insertion, Care and Maintenance proficiency*

Peripheral IV Insertion, Care and Maintenance frequency*

PICC Line Care and Maintenance *

PICC Line Care and Maintenance proficiency*

PICC Line Care and Maintenance frequency*

Central Line Care and Maintenance *

Central Line Care and Maintenance proficiency*

Central Line Care and Maintenance frequency*

Port - A - Cath Access, Care and Maintenance *

Port - A - Cath Access, Care and Maintenance proficiency*

Port - A - Cath Access, Care and Maintenance frequency*

Drawing Labwork from Central Line / Port *

Drawing Labwork from Central Line / Port proficiency*

Drawing Labwork from Central Line / Port frequency*

Administration of Blood / Blood Products *

Administration of Blood / Blood Products proficiency*

Administration of Blood / Blood Products frequency*

Tubes / Drains - Care of Patient with:

Proficiency Rating

Frequency Rating

Penrose Drain *

Penrose Drain proficiency*

Penrose Drain frequency*

Jackson Pratt *

Jackson Pratt proficiency*

Jackson Pratt frequency*

T Tube *

T Tube proficiency*

T Tube frequency*

Hemovac *

Hemovac proficiency*

Hemovac frequency*

Operate & Monitor Unit Equipment

Proficiency Rating

Frequency Rating

Portable Suction Machine *

Portable Suction Machine proficiency*

Portable Suction Machine frequency*

Transport Monitor *

Transport Monitor proficiency*

Transport Monitor frequency*

Automatic BP Monitor *

Automatic BP Monitor proficiency*

Automatic BP Monitor frequency*

Blanket Warmer / Bear Hugger *

Blanket Warmer / Bear Hugger proficiency*

Blanket Warmer / Bear Hugger frequency*

Sequential Compression Device *

Sequential Compression Device proficiency*

Sequential Compression Device frequency*

Pulse Oximeter *

Pulse Oximeter proficiency*

Pulse Oximeter frequency*

Hyper / Hypothermia Blanket *

Hyper / Hypothermia Blanket proficiency*

Hyper / Hypothermia Blanket frequency*

Blood Warmer *

Blood Warmer proficiency*

Blood Warmer frequency*

PACU Stretcher *

PACU Stretcher proficiency*

PACU Stretcher frequency*

IV Pumps *

IV Pumps proficiency*

IV Pumps frequency*

Anesthesia Equipment

Proficiency Rating

Frequency Rating

Nitrogen Controls *

Nitrogen Controls proficiency*

Nitrogen Controls frequency*

Tanks *

Tanks proficiency*

Tanks frequency*

Wall Units *

Wall Units proficiency*

Wall Units frequency*

Discharge

Proficiency Rating

Frequency Rating

Perform A Discharge Physical *

Perform A Discharge Physical proficiency*

Perform A Discharge Physical frequency*

Level of Consciousness *

Level of Consciousness proficiency*

Level of Consciousness frequency*

Pupillary Reactions *

Pupillary Reactions proficiency*

Pupillary Reactions frequency*

Motor & Sensory Function *

Motor & Sensory Function proficiency*

Motor & Sensory Function frequency*

Muscular Strength (e.g. Hand grasps, Head lift) *

Muscular Strength (e.g. Hand grasps, Head lift) proficiency*

Muscular Strength (e.g. Hand grasps, Head lift) frequency*

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