Emerson Pump Nasal Tracheal suctioning Infusion Pump Feeding Pump Equipment procedures



Telemetry Skills Checklist

First Name   MI    Last Name   Date

 
  • By placing my name on this form, I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. 

 
 

The following checklist is used to assess your experience and skills

  1. No experience
  2. Minimal experience
  3. Proficient, would not require supervision or practice
  4. Able to supervise and can act as a resource person

 
 
 

Cardiovascular 0 1 2 3
Assessment- Pulses        
  • Peripheral Edema
 ☐ ☐ ☐ ☐
  • Cardiac Dysrhythmias
 ☐ ☐ ☐ ☐
  • Junctional Dysrhythmias
 ☐ ☐ ☐ ☐
  • Pacemaker Rhythms
 ☐ ☐ ☐ ☐
  • Twelve lead EKG
 ☐ ☐ ☐ ☐
Equipment        
  • Central Cardiac Monitoring System
 ☐ ☐ ☐ ☐
  • Doppler
 ☐ ☐ ☐ ☐
  • Resuscitation w/ACLS protocol
 ☐ ☐ ☐ ☐
  • Inspection of Chest to include Rate
 ☐ ☐ ☐ ☐
  • ABG’s
 ☐ ☐ ☐ ☐
  • Use of Face tents
 ☐ ☐ ☐ ☐
  • Use of Nasal Trumpet
 ☐ ☐ ☐ ☐
Care of the patient with:        
  • Use of Emerson Pump
 ☐ ☐ ☐ ☐
  • Use of Nasal Tracheal suctioning
 ☐ ☐ ☐ ☐
  • Assist with Chest Tube removal
 ☐ ☐ ☐ ☐
  • CT Scan
 ☐ ☐ ☐ ☐
  • Hyperthermia Blanket
 ☐ ☐ ☐ ☐
  • Prepare & Assist W/ Insertion of Central Line
 ☐ ☐ ☐ ☐
  • Foley Drainage & Irrigation Devices
 ☐ ☐ ☐ ☐
  • Percussion & Palpation of Abdomen
 ☐ ☐ ☐ ☐
  • Dobb-Hoff Tube
 ☐ ☐ ☐ ☐
  • Gomco Suction
 ☐ ☐ ☐ ☐
  • Removal of Various Gastric Tubes
 ☐ ☐ ☐ ☐
  • Jackson-Pratt Drain
 ☐ ☐ ☐ ☐
  • Use/Administration of Pronestyl
 ☐ ☐ ☐ ☐
  • Use/Administration of Dobutrex
 ☐ ☐ ☐ ☐

 
 

Pulmonary 0 1 2 3
Assessment        
  • Blood Pressure
 ☐ ☐ ☐ ☐
  • Heart Sounds
 ☐ ☐ ☐ ☐
Interpretation of lab results        
  • Sinus Dysrhythmias
 ☐ ☐ ☐ ☐
  • Ventricular Dysrhythmias
 ☐ ☐ ☐ ☐
Equipment & procedures        
  • Cardiac Enzymes
 ☐ ☐ ☐ ☐
  • Cardiac Scans
 ☐ ☐ ☐ ☐
  • Portable Cardiac Monitoring System
 ☐ ☐ ☐ ☐
  • Defibrillation
 ☐ ☐ ☐ ☐
  • Calculate dosages of Cardiac
 ☐ ☐ ☐ ☐
  • Inspection of Chest to include Rhythm
 ☐ ☐ ☐ ☐
  • Radio graphic Pulmonary
 ☐ ☐ ☐ ☐
  • Uses of Face Masks
 ☐ ☐ ☐ ☐
  • Use of Oral Airway
 ☐ ☐ ☐ ☐
  • Use of Pleur-E-Vac
 ☐ ☐ ☐ ☐
  • Prepare & Assist with Chest Tube Insertion
 ☐ ☐ ☐ ☐
  • Neuro Check/Glasgow Coma Scale
 ☐ ☐ ☐ ☐
  • Spinal Tap Results
 ☐ ☐ ☐ ☐
  • Urinary Output – Color & Amount
 ☐ ☐ ☐ ☐
  • Maintenance of Central Line
 ☐ ☐ ☐ ☐
  • Infusion Pump
 ☐ ☐ ☐ ☐
  • Salem Sump Tube
 ☐ ☐ ☐ ☐
  • Enteroflex
 ☐ ☐ ☐ ☐
  • Insertion of Various Gastric
 ☐ ☐ ☐ ☐
  • J-Vac Drain
 ☐ ☐ ☐ ☐
  • Hemovac
 ☐ ☐ ☐ ☐
Care of patients with:        
  • Use/Administration of Heparin
 ☐ ☐ ☐ ☐

 

Neurological 0 1 2 3
Assessment        
  • Capillary Refill
 ☐ ☐ ☐ ☐
  • Neck Vain Distention
 ☐ ☐ ☐ ☐
Equipment and Procedures        
  • Atrial Dysrhythmias
 ☐ ☐ ☐ ☐
  • Heart Blocks
 ☐ ☐ ☐ ☐
Care of the patient with:        
  • Electrolytes
 ☐ ☐ ☐ ☐
  • Bedside Cardiac monitoring System
 ☐ ☐ ☐ ☐
  • Dinamap
 ☐ ☐ ☐ ☐
  • Cardioversion
 ☐ ☐ ☐ ☐
  • Inspection of Chest to include Respirations
 ☐ ☐ ☐ ☐
  • Palpation & Percussion of Chest Lung Sounds
 ☐ ☐ ☐ ☐
  • Use of Nasal Cannula
 ☐ ☐ ☐ ☐
  • Use of Ambu Bag
 ☐ ☐ ☐ ☐
  • Use of Chest Tube
 ☐ ☐ ☐ ☐
  • Use of Thoraflex
 ☐ ☐ ☐ ☐
  • Chest Tuba Maintenance
 ☐ ☐ ☐ ☐
  • EEG
 ☐ ☐ ☐ ☐
  • Hypothermia Blanket
 ☐ ☐ ☐ ☐
  • Test Urine, S/A, BUN, Crea, NA, K+
 ☐ ☐ ☐ ☐

 

Orthopedics 0 1 2 3
Assessment        
  • Removal of Central Line
 ☐ ☐ ☐ ☐
  • Auscultation of Abdomen
 ☐ ☐ ☐ ☐
  • Levine Tube
 ☐ ☐ ☐ ☐
  • Feeding Pump
 ☐ ☐ ☐ ☐
Equipment & procedures        
  • Maintenance of Various Gastric Tubes
 ☐ ☐ ☐ ☐
  • Penrose Drain
 ☐ ☐ ☐ ☐
  • Use / Administration of Lidocain
 ☐ ☐ ☐ ☐
  • Use/Administration of Dopamine
 ☐ ☐ ☐ ☐






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    Emerson Pump Nasal Tracheal suctioning Infusion Pump Feeding Pump Equipment procedures

    Telemetry Skills Checklist

    First Name   MI    Last Name   Date

     
    • By placing my name on this form, I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. 

     
     

    The following checklist is used to assess your experience and skills

    1. No experience
    2. Minimal experience
    3. Proficient, would not require supervision or practice
    4. Able to supervise and can act as a resource person

     
     
     

    Cardiovascular 0 1 2 3
    Assessment- Pulses        
    • Peripheral Edema
    		 ☐ ☐ ☐ ☐
    • Cardiac Dysrhythmias
    		 ☐ ☐ ☐ ☐
    • Junctional Dysrhythmias
    		 ☐ ☐ ☐ ☐
    • Pacemaker Rhythms
    		 ☐ ☐ ☐ ☐
    • Twelve lead EKG
    		 ☐ ☐ ☐ ☐
    Equipment        
    • Central Cardiac Monitoring System
    		 ☐ ☐ ☐ ☐
    • Doppler
    		 ☐ ☐ ☐ ☐
    • Resuscitation w/ACLS protocol
    		 ☐ ☐ ☐ ☐
    • Inspection of Chest to include Rate
    		 ☐ ☐ ☐ ☐
    • ABG’s
    		 ☐ ☐ ☐ ☐
    • Use of Face tents
    		 ☐ ☐ ☐ ☐
    • Use of Nasal Trumpet
    		 ☐ ☐ ☐ ☐
    Care of the patient with:        
    • Use of Emerson Pump
    		 ☐ ☐ ☐ ☐
    • Use of Nasal Tracheal suctioning
    		 ☐ ☐ ☐ ☐
    • Assist with Chest Tube removal
    		 ☐ ☐ ☐ ☐
    • CT Scan
    		 ☐ ☐ ☐ ☐
    • Hyperthermia Blanket
    		 ☐ ☐ ☐ ☐
    • Prepare & Assist W/ Insertion of Central Line
    		 ☐ ☐ ☐ ☐
    • Foley Drainage & Irrigation Devices
    		 ☐ ☐ ☐ ☐
    • Percussion & Palpation of Abdomen
    		 ☐ ☐ ☐ ☐
    • Dobb-Hoff Tube
    		 ☐ ☐ ☐ ☐
    • Gomco Suction
    		 ☐ ☐ ☐ ☐
    • Removal of Various Gastric Tubes
    		 ☐ ☐ ☐ ☐
    • Jackson-Pratt Drain
    		 ☐ ☐ ☐ ☐
    • Use/Administration of Pronestyl
    		 ☐ ☐ ☐ ☐
    • Use/Administration of Dobutrex
    		 ☐ ☐ ☐ ☐

     
     

    Pulmonary 0 1 2 3
    Assessment        
    • Blood Pressure
    		 ☐ ☐ ☐ ☐
    • Heart Sounds
    		 ☐ ☐ ☐ ☐
    Interpretation of lab results        
    • Sinus Dysrhythmias
    		 ☐ ☐ ☐ ☐
    • Ventricular Dysrhythmias
    		 ☐ ☐ ☐ ☐
    Equipment & procedures        
    • Cardiac Enzymes
    		 ☐ ☐ ☐ ☐
    • Cardiac Scans
    		 ☐ ☐ ☐ ☐
    • Portable Cardiac Monitoring System
    		 ☐ ☐ ☐ ☐
    • Defibrillation
    		 ☐ ☐ ☐ ☐
    • Calculate dosages of Cardiac
    		 ☐ ☐ ☐ ☐
    • Inspection of Chest to include Rhythm
    		 ☐ ☐ ☐ ☐
    • Radio graphic Pulmonary
    		 ☐ ☐ ☐ ☐
    • Uses of Face Masks
    		 ☐ ☐ ☐ ☐
    • Use of Oral Airway
    		 ☐ ☐ ☐ ☐
    • Use of Pleur-E-Vac
    		 ☐ ☐ ☐ ☐
    • Prepare & Assist with Chest Tube Insertion
    		 ☐ ☐ ☐ ☐
    • Neuro Check/Glasgow Coma Scale
    		 ☐ ☐ ☐ ☐
    • Spinal Tap Results
    		 ☐ ☐ ☐ ☐
    • Urinary Output – Color & Amount
    		 ☐ ☐ ☐ ☐
    • Maintenance of Central Line
    		 ☐ ☐ ☐ ☐
    • Infusion Pump
    		 ☐ ☐ ☐ ☐
    • Salem Sump Tube
    		 ☐ ☐ ☐ ☐
    • Enteroflex
    		 ☐ ☐ ☐ ☐
    • Insertion of Various Gastric
    		 ☐ ☐ ☐ ☐
    • J-Vac Drain
    		 ☐ ☐ ☐ ☐
    • Hemovac
    		 ☐ ☐ ☐ ☐
    Care of patients with:        
    • Use/Administration of Heparin
    		 ☐ ☐ ☐ ☐

     

    Neurological 0 1 2 3
    Assessment        
    • Capillary Refill
    		 ☐ ☐ ☐ ☐
    • Neck Vain Distention
    		 ☐ ☐ ☐ ☐
    Equipment and Procedures        
    • Atrial Dysrhythmias
    		 ☐ ☐ ☐ ☐
    • Heart Blocks
    		 ☐ ☐ ☐ ☐
    Care of the patient with:        
    • Electrolytes
    		 ☐ ☐ ☐ ☐
    • Bedside Cardiac monitoring System
    		 ☐ ☐ ☐ ☐
    • Dinamap
    		 ☐ ☐ ☐ ☐
    • Cardioversion
    		 ☐ ☐ ☐ ☐
    • Inspection of Chest to include Respirations
    		 ☐ ☐ ☐ ☐
    • Palpation & Percussion of Chest Lung Sounds
    		 ☐ ☐ ☐ ☐
    • Use of Nasal Cannula
    		 ☐ ☐ ☐ ☐
    • Use of Ambu Bag
    		 ☐ ☐ ☐ ☐
    • Use of Chest Tube
    		 ☐ ☐ ☐ ☐
    • Use of Thoraflex
    		 ☐ ☐ ☐ ☐
    • Chest Tuba Maintenance
    		 ☐ ☐ ☐ ☐
    • EEG
    		 ☐ ☐ ☐ ☐
    • Hypothermia Blanket
    		 ☐ ☐ ☐ ☐
    • Test Urine, S/A, BUN, Crea, NA, K+
    		 ☐ ☐ ☐ ☐

     

    Orthopedics 0 1 2 3
    Assessment        
    • Removal of Central Line
    		 ☐ ☐ ☐ ☐
    • Auscultation of Abdomen
    		 ☐ ☐ ☐ ☐
    • Levine Tube
    		 ☐ ☐ ☐ ☐
    • Feeding Pump
    		 ☐ ☐ ☐ ☐
    Equipment & procedures        
    • Maintenance of Various Gastric Tubes
    		 ☐ ☐ ☐ ☐
    • Penrose Drain
    		 ☐ ☐ ☐ ☐
    • Use / Administration of Lidocain
    		 ☐ ☐ ☐ ☐
    • Use/Administration of Dopamine
    		 ☐ ☐ ☐ ☐
    << event incompatible drug administration a separate HCPCS shall allow rental a second infusion pumpdevice researchers purpose called an infusion pump a mechanical syringe You can adjust fast pump >>