Perfusionist

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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*

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:

Patient Head to Toe Assessment *

Patient Head to Toe Assessment proficiency*

Patient Head to Toe Assessment frequency*

Dressing Changes *

Dressing Changes proficiency*

Dressing Changes frequency*

Knowledge of Normal Serum Lab Values *

Knowledge of Normal Serum Lab Values proficiency*

Knowledge of Normal Serum Lab Values frequency*

Obtaining Cultures (Blood, Sputum, Swab) *

Obtaining Cultures (Blood, Sputum, Swab) proficiency*

Obtaining Cultures (Blood, Sputum, Swab) frequency*

Administration of Blood & Blood Products *

Administration of Blood & Blood Products proficiency*

Administration of Blood & Blood Products frequency*

PCA Pumps *

PCA Pumps proficiency*

PCA Pumps frequency*

Infusion Pump *

Infusion Pump proficiency*

Infusion Pump frequency*

Calculate mcg / min and mcg / kg / min *

Calculate mcg / min and mcg / kg / min proficiency*

Calculate mcg / min and mcg / kg / min frequency*

Titrating Medications *

Titrating Medications proficiency*

Titrating Medications frequency*

Knowledge and Use of

Proficiency Rating

Frequency Rating

Sedatives *

Sedatives proficiency*

Sedatives frequency*

Analgesics *

Analgesics proficiency*

Analgesics frequency*

Propofol *

Propofol proficiency*

Propofol frequency*

Epinephrine *

Epinephrine proficiency*

Epinephrine frequency*

Vasopressin *

Vasopressin proficiency*

Vasopressin frequency*

Amiodarone *

Amiodarone proficiency*

Amiodarone frequency*

TPA *

TPA proficiency*

TPA frequency*

Atropine *

Atropine proficiency*

Atropine frequency*

Bretylol *

Bretylol proficiency*

Bretylol frequency*

Bumex *

Bumex proficiency*

Bumex frequency*

Digoxin *

Digoxin proficiency*

Digoxin frequency*

Dopamine *

Dopamine proficiency*

Dopamine frequency*

Dobutrex *

Dobutrex proficiency*

Dobutrex frequency*

Heparin Drip (Precautions & Maintenance) *

Heparin Drip (Precautions & Maintenance) proficiency*

Heparin Drip (Precautions & Maintenance) frequency*

Inderal *

Inderal proficiency*

Inderal frequency*

Inocor *

Inocor proficiency*

Inocor frequency*

Isuprel *

Isuprel proficiency*

Isuprel frequency*

Lidocaine *

Lidocaine proficiency*

Lidocaine frequency*

Neosynephrine/Nipride *

Neosynephrine/Nipride proficiency*

Neosynephrine/Nipride frequency*

Nitroglycerin *

Nitroglycerin proficiency*

Nitroglycerin frequency*

Pronestyl *

Pronestyl proficiency*

Pronestyl frequency*

Titrate Morphine *

Titrate Morphine proficiency*

Titrate Morphine frequency*

Thrombolytic Agents *

Thrombolytic Agents proficiency*

Thrombolytic Agents frequency*

Magnesium Sulfate *

Magnesium Sulfate proficiency*

Magnesium Sulfate frequency*

Versed *

Versed proficiency*

Versed frequency*

Prep/Titration of Emergency Drugs *

Prep/Titration of Emergency Drugs proficiency*

Prep/Titration of Emergency Drugs frequency*

Cardiac General Skills

Proficiency Rating

Frequency Rating

Interpretation of 12 lead EKG *

Interpretation of 12 lead EKG proficiency*

Interpretation of 12 lead EKG frequency*

Interpretation of Arrhythmias *

Interpretation of Arrhythmias proficiency*

Interpretation of Arrhythmias frequency*

Defibrillation/Cardioversion *

Defibrillation/Cardioversion proficiency*

Defibrillation/Cardioversion frequency*

Permanent Pacemaker *

Permanent Pacemaker proficiency*

Permanent Pacemaker frequency*

Temporary Pacemaker *

Temporary Pacemaker proficiency*

Temporary Pacemaker frequency*

AICD *

AICD proficiency*

AICD frequency*

Interpretation of Hemodynamic Monitoring *

Interpretation of Hemodynamic Monitoring proficiency*

Interpretation of Hemodynamic Monitoring frequency*

Art-Line (Transducer set-up, D/C) *

Art-Line (Transducer set-up, D/C) proficiency*

Art-Line (Transducer set-up, D/C) frequency*

Swan-Ganz (Transducer set-up, D/C) *

Swan-Ganz (Transducer set-up, D/C) proficiency*

Swan-Ganz (Transducer set-up, D/C) frequency*

Balloon Pump (IABP) *

Balloon Pump (IABP) proficiency*

Balloon Pump (IABP) frequency*

SVO2 Monitoring *

SVO2 Monitoring proficiency*

SVO2 Monitoring frequency*

Sheath Removal *

Sheath Removal proficiency*

Sheath Removal frequency*

Interpretation of Cardiac Enzymes *

Interpretation of Cardiac Enzymes proficiency*

Interpretation of Cardiac Enzymes frequency*

Cardiac - Care of Patient with:

Proficiency Rating

Frequency Rating

Aneurysm *

Aneurysm proficiency*

Aneurysm frequency*

Acute MI/Unstable Angina *

Acute MI/Unstable Angina proficiency*

Acute MI/Unstable Angina frequency*

CHF *

CHF proficiency*

CHF frequency*

Cardiogenic/Hypovolemic Shock *

Cardiogenic/Hypovolemic Shock proficiency*

Cardiogenic/Hypovolemic Shock frequency*

Pre/Post Cardiac Surgery *

Pre/Post Cardiac Surgery proficiency*

Pre/Post Cardiac Surgery frequency*

Pre/Post Cardiac Cath *

Pre/Post Cardiac Cath proficiency*

Pre/Post Cardiac Cath frequency*

Percutaneous Transluminal Coronary Angioplasty *

Percutaneous Transluminal Coronary Angioplasty proficiency*

Percutaneous Transluminal Coronary Angioplasty frequency*

Heart Transplant *

Heart Transplant proficiency*

Heart Transplant frequency*

Respiratory General Skills

Proficiency Rating

Frequency Rating

Establishing an Airway *

Establishing an Airway proficiency*

Establishing an Airway frequency*

Oxygen Delivery Systems *

Oxygen Delivery Systems proficiency*

Oxygen Delivery Systems frequency*

Chest Tubes (Emerson/Pleuravac) *

Chest Tubes (Emerson/Pleuravac) proficiency*

Chest Tubes (Emerson/Pleuravac) frequency*

Pulse Oximetry *

Pulse Oximetry proficiency*

Pulse Oximetry frequency*

Interpretation of ABG *

Interpretation of ABG proficiency*

Interpretation of ABG frequency*

Drawing ABG Blood Sample from Art-Line *

Drawing ABG Blood Sample from Art-Line proficiency*

Drawing ABG Blood Sample from Art-Line frequency*

Use of IPPB *

Use of IPPB proficiency*

Use of IPPB frequency*

Use of Pressure Support *

Use of Pressure Support proficiency*

Use of Pressure Support frequency*

Suctioning *

Suctioning proficiency*

Suctioning frequency*

Vascular General Skills

Proficiency Rating

Frequency Rating

Peripheral Pulses *

Peripheral Pulses proficiency*

Peripheral Pulses frequency*

Dopplers *

Dopplers proficiency*

Dopplers frequency*

Peripheral IV Insertion, Care and Maintenance *

Peripheral IV Insertion, Care and Maintenance proficiency*

Peripheral IV Insertion, Care and Maintenance frequency*

Assisting with Insertion of Central Lines *

Assisting with Insertion of Central Lines proficiency*

Assisting with Insertion of Central Lines frequency*

Care and Maintenance of Central Lines *

Care and Maintenance of Central Lines proficiency*

Care and Maintenance of Central Lines frequency*

Assist with IV Cutdown *

Assist with IV Cutdown proficiency*

Assist with IV Cutdown frequency*

Other

Proficiency Rating

Frequency Rating

Care of Oncology Patient *

Care of Oncology Patient proficiency*

Care of Oncology Patient frequency*

Chemotherapy Administration *

Chemotherapy Administration proficiency*

Chemotherapy Administration frequency*

Care of Patient with Burns *

Care of Patient with Burns proficiency*

Care of Patient with Burns frequency*

Care of Patient with HIV/AIDS *

Care of Patient with HIV/AIDS proficiency*

Care of Patient with HIV/AIDS frequency*

Hyperbaric Oxygenation *

Hyperbaric Oxygenation proficiency*

Hyperbaric Oxygenation frequency*

Suicide Precautions *

Suicide Precautions proficiency*

Suicide Precautions frequency*

Post Mortem Care *

Post Mortem Care proficiency*

Post Mortem Care frequency*

Perfusionist Skills

Proficiency Rating

Frequency Rating

Patient identification *

Patient identification proficiency*

Patient identification frequency*

Procedure confirmation *

Procedure confirmation proficiency*

Procedure confirmation frequency*

Blood type, antibodies confirmed *

Blood type, antibodies confirmed proficiency*

Blood type, antibodies confirmed frequency*

Allergies checked *

Allergies checked proficiency*

Allergies checked frequency*

Blood bank number confirmed *

Blood bank number confirmed proficiency*

Blood bank number confirmed frequency*

Medical record number confirmed *

Medical record number confirmed proficiency*

Medical record number confirmed frequency*

Chart review *

Chart review proficiency*

Chart review frequency*

Components checked for package integrity/expiration *

Components checked for package integrity/expiration proficiency*

Components checked for package integrity/expiration frequency*

Equipment clean *

Equipment clean proficiency*

Equipment clean frequency*

Heat exchanger(s) leak-tested *

Heat exchanger(s) leak-tested proficiency*

Heat exchanger(s) leak-tested frequency*

Occlusion(s) set *

Occlusion(s) set proficiency*

Occlusion(s) set frequency*

Speed controls operational *

Speed controls operational proficiency*

Speed controls operational frequency*

Flow meter *

Flow meter proficiency*

Flow meter frequency*

Rollers, Pump Head & Holder Checks *

Rollers, Pump Head & Holder Checks proficiency*

Rollers, Pump Head & Holder Checks frequency*

Servo-regulated connections *

Servo-regulated connections proficiency*

Servo-regulated connections frequency*

Cardioplegia-System Checks *

Cardioplegia-System Checks proficiency*

Cardioplegia-System Checks frequency*

Knowledge of Gas line(s) and filer connection *

Knowledge of Gas line(s) and filer connection proficiency*

Knowledge of Gas line(s) and filer connection frequency*

Gas exhaust *

Gas exhaust proficiency*

Gas exhaust frequency*

Flow meter / gas blender operational *

Flow meter / gas blender operational proficiency*

Flow meter / gas blender operational frequency*

Hoses leak-free *

Hoses leak-free proficiency*

Hoses leak-free frequency*

Anesthetic gas scavenge line *

Anesthetic gas scavenge line proficiency*

Anesthetic gas scavenge line frequency*

Alarms operational *

Alarms operational proficiency*

Alarms operational frequency*

Arterial filter / bubble trap debubbled *

Arterial filter / bubble trap debubbled proficiency*

Arterial filter / bubble trap debubbled frequency*

Vent(s) tested *

Vent(s) tested proficiency*

Vent(s) tested frequency*

Venous line occluder(s) calibrated and tested *

Venous line occluder(s) calibrated and tested proficiency*

Venous line occluder(s) calibrated and tested frequency*

Devices securely attached *

Devices securely attached proficiency*

Devices securely attached frequency*

Cardiotomy positive-pressure relief valve *

Cardiotomy positive-pressure relief valve proficiency*

Cardiotomy positive-pressure relief valve frequency*

Negative- pressure relief valve *

Negative- pressure relief valve proficiency*

Negative- pressure relief valve frequency*

Vacuum regulator *

Vacuum regulator proficiency*

Vacuum regulator frequency*

Circuit / patient temperature probes *

Circuit / patient temperature probes proficiency*

Circuit / patient temperature probes frequency*

Pressure transducers *

Pressure transducers proficiency*

Pressure transducers frequency*

Inline sensors *

Inline sensors proficiency*

Inline sensors frequency*

Oxygen analyzer *

Oxygen analyzer proficiency*

Oxygen analyzer frequency*

Water source(s) *

Water source(s) proficiency*

Water source(s) frequency*

Temperature range(s) *

Temperature range(s) proficiency*

Temperature range(s) frequency*

Water lines *

Water lines proficiency*

Water lines frequency*

Tubing clamps *

Tubing clamps proficiency*

Tubing clamps frequency*

Drugs available and properly labeled *

Drugs available and properly labeled proficiency*

Drugs available and properly labeled frequency*

Solutions *

Solutions proficiency*

Solutions frequency*

Blood products *

Blood products proficiency*

Blood products frequency*

Sampling syringes / laboratory tubes *

Sampling syringes / laboratory tubes proficiency*

Sampling syringes / laboratory tubes frequency*

Anesthetic vaporizer *

Anesthetic vaporizer proficiency*

Anesthetic vaporizer frequency*

Vaporizer *

Vaporizer proficiency*

Vaporizer frequency*

Hand cranks *

Hand cranks proficiency*

Hand cranks frequency*

Duplicate circuit components / hardware *

Duplicate circuit components / hardware proficiency*

Duplicate circuit components / hardware frequency*

Emergency lighting / flashlight *

Emergency lighting / flashlight proficiency*

Emergency lighting / flashlight frequency*

Emergent restart of Bypass *

Emergent restart of Bypass proficiency*

Emergent restart of Bypass frequency*

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Date*

Skills/Competences

Proficiency

Frequency

PERFUSIONIST

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