Cath Lab RN

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Director of Rehab

OT

COTA

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SLP/SLPA

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Director of Nursing

LPN

MDS Coordinator

Medication Aide

LTC RN

Ambulatory RN

Antepartum Postpartum Nursery

Behavioral Health RN

Case Management

Cath Lab RN

Certified Surgical First Assistant

Clinic RN

CVICU RN

CVOR RN

CVOR Surgical Tech

Dialysis RN

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ER RN

High Risk Skills

Home Health RN

Infection Prevention RN

Intensive Care RN

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LDRP RN

LTAC RN

Maternal Fetal/High Risk

Medical Assistant

Medical Surgical / Telemetry

Neonatal Intensive Care

Nurse Manager

OB Tech

Oncology

OR RN

OR/Surg Tech

PACU

Pediatric Emergency Room

Pediatric Intensive Care

Pediatric RN

Rehab RN

Sterile Processing Technologist

Surgical Tech

Tele, PCU, Stepdown RN

Transplant Coordinator RN

Home Health Case Manager

Home Health Clinical Manager

Home Infusion RN

Home Health LPN

Home Health RN

Hospice LPN

Hospice RN

Cath

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Echo

High Risk Skills

Histotechnologist

Interventional Skills

Mammography Skills

MRI Technologist

Nuclear Medicine Technologist

OR/Surg Tech

Pharmacist

Pharmacy Technician

Radiologic Technologist

Radiation Therapist

Sterile Processing Tech

Ultrasound Tech

Vascular Ultrasound

Cytotechnologist

Histotechnologist

Medical Laboratory Technologist

Medical Technologist

Pathologist Assistant

Phlebotomy

Cath Lab RN

Cath Lab Technologist

Cath EP

Interventional Skills

Anesthesia Tech

Dietician

EKG Tech

Perfusionist

Polysomnographer / RPSGT

Respiratory Therapist

This self evaluation is for assessing your experience in specific clinical areas. This self evaluation will not be a determining factor in accepting your application to become an employee of Luvo Healthcare.
- 0 = Not Applicable
- 1 = No Experience
- 2 = Some Experience
- 3 = Intermittent Experience
- 4 = Experienced
- 5 = Very Experienced
*Required Field
GENERAL SKILLS

0 1 2 3 4 5

Proficiency Rating
Universal Precautions*
Care of Patient in Isolation*
Care of Patient with Bleeding Precautions*
Care of Patient with Neutropenic Precautions*
Care of Patient in Restraints*
Cardiac Monitoring - Basic*
Cardiac Monitoring - Advanced*
Interpretation of Arrhythmias*
Emergency Medications (ACLS)*
Pediatric Cardiac / Respiratory Arrest*
Adult Cardiac / Respiratory Arrest*
End of Life Care*
Crash Carts*
Defibrillators*
Automated Medication Dispensing Systems*
List Types:
Computerized Documentation*
List Types:

ASSESSMENT

0	1	2	3	4	5

Proficiency Rating

Abnormal Heart Sounds*
Murmurs*
Peripheral Pulse / Circulation Checks*
Use of Doppler*
Blood Pressure - Invasive*
Blood Pressure – Non-Invasive*
Evaluate Chest Pain*

MONITORING / TELEMETRY

0	1	2	3	4	5

Proficiency Rating

Basic 12 Lead EKG Interpretation*
Arrhythmia Interpretation*
Lead Placement: 5 Electrodes*
Lead Placement: I, II, V-leads*
Lead Placement: Lead II and MCL*
Set up and Perform 12 Lead EKG*
Rhythm Strip Interpretation*

HEMODYNAMIC MONITORING

0	1	2	3	4	5

Proficiency Rating

Biopsy*
Handoff Reports*
Left Heart Caths*
Right Heart Caths*
Coronary Intervention*
Hematoma Recognition & Mgt*
Coronary Atherectomy*
IVUS*
Intra Aortic Balloon Pump*
EP Study*
Ablation*
Rotablator*
FFR*

INTERPRETATION OF LAB RESULTS

0	1	2	3	4	5

Proficiency Rating

Cardiac Enzymes*
GFR Bun Creatinine*
Coagulation Studies*
Chemistries*
Other - Specify:
Other - Rate*

IV THERAPY

0	1	2	3	4	5

Proficiency Rating

Assist with Care and Maintenance of:

Central Line*
Arterial Line*
Swan-Ganz Catheter*

PULMONARY

0	1	2	3	4	5

Proficiency Rating

Assess Lung Sounds*
Pulse Oximetry*
Set UP Oxygen Delivery Devices*
Obtain and Interpret ABGs*
Obtain and Interpret Mixed Venous Gases*
Assist with Intubation*

NEUROLOGICAL

0	1	2	3	4	5

Proficiency Rating

Neuro Assessment*
Assess Sensory, Motor, Speech Function*
Glasgow Coma Scale*

MEDICATION

0	1	2	3	4	5

Proficiency Rating

Contrast Media*
Sedation Meds*
Reversal Meds*
Anticoagulation*
Thrombolytics*
Lopressor (Metoprolol)*
Dilatiazem HCL (Cardizem)*
Verapamil (Calan)*
Nitrostat (Nitroglycerin)*
Adenocard (Adenosine)*
Amiodarone (Cardarone)*
Corvert (Ibutilide)*
Lidocaine*
Pronestyl*
Atropine*
Sodium Nitroprusside (Nipride)*
Inocor (Amrinone)*
Milrinone (Primacor)*
Adrenalin (Epinephrine)*
Dobutrex (Dobutamine)*
Dopamine Hydrochloride*
Sodium Bicarbonate*
Furosemide (Lasix)*
Insulin*
IV Antibiotics*

SITE MANAGEMENT / SHEATHS:

0	1	2	3	4	5

Proficiency Rating

Assist with Removal of:

Femoral Arterial Sheath*
Femoral Venous Sheath*
Brachial Arterial Sheath*
Radial Arterial Sheath*
Manual Pressure Hold*
Hematoma Recognition/Mgmt*
Closure Devices*

PATIENT CARE

0	1	2	3	4	5

Proficiency Rating

Application of Sterile Pressure Dressing*
Allen Test*
Radiation Safety*
Maintain Sheaths in Place*
Skin Prep and Clipping*
Aseptic Technique*
Knowledge of Pediatric Cardiac Anomalies*
Identify Sudden Change in LOC*
Post Procedure/Recorvery*

CATH LAB PROCEDURES / SCRUB

0	1	2	3	4	5

Proficiency Rating

Cardiac Catheterization – Adult (L)*
Cardiac Catheterization – Adult (R)*
Cardiac Catheterization – Peds (L)*
Cardiac Catheterization – Peds (R)*
Permanent Pacemaker*
Temporary Epicardial/Transthoratic Pacing*
Temporary External Pacing*
Temporary Transvenous Pacing*
Peripheral*
Cardiac Cath Lab Procedures*

EMERGENCY PROCEDURES:

0	1	2	3	4	5

Proficiency Rating

Emergency Cardioversion*
Anaphylaxis (Contras Media)*
Vasovagal Response*
Sepsis/Septic Shock*
Cardiac Tamponade*
Cardiogenic Shock*
Emobolism*
Myocardial Infarction*
TIA*
Aortic Dissection*
Cardiac / Respiratory*
Emergency Defibrillation*

Cath Lab Procedures / Circulate:

Cardiac Cath – Adult (L)*
Cardiac Cath – Adult (R)*
Cardiac Cath – Peds (L)*
Cardiac Cath – Peds (R)*
Permanent Pacemaker*
Temporary Pacing*
AICD Pacemakers / Biventricular Pacer*
Angioplasty/PCI*
Arrhythmia Ablation*
Thromolysis*
AngioJet*
Rotational Coronary Atherectomy*
Cardiac Biopsy*
Pericardiocentesis*
Chest Tube Placement*
Valvuplasty*
IABP*
TEE*
CAVH*
Controlled Cardioversion*
Closure of ASD*
Closure of VSD*
Closure of Patent Foramen Ovale*
Tilt Table Testing*
Brachytherapy*
Intravascular Ultrasound*

Cath Lab PROCEDURES / MONITOR

0	1	2	3	4	5

Proficiency Rating

Cardiac Cath – Adult (L)*
Cardiac Cath – Adult (R)*
Cardiac Cath – Peds (L)*
Cardiac Cath – Peds (R)*
Permanent Pacemaker*
Temporary Pacing*
AICD Pacemakers / Biventricular Pacer*
Shunt Detection and Calculation*
Angioplasty/PCI*
Left Ventricular Assist Device*
Right Ventricular Assist Device*
Ablation*
AngioJet*
Rotational Coronary Atherectomy*
Pericardiocentesis*
Angiography*
Cardiac Biopsy*
Pericardiocentesis*
Chest Tube Placement*
Valvuplasty*
IABP*
TEE*
CAVH*
Controlled Cardioversion*
Closure of ASD*
Closure of VSD*
Closure of Patent Foramen Ovale*
Tilt Table Testing*
Brachytherapy*
Intravascular Ultrasound*
FFR*
Emergency Procedures*

MISCELLANEOUS

List Any Additional Skills:
List Hemodynamic Systems Worked With Before:
List Any Additional Equipment:

Age-Appropriate Care: Ability to adapt care to incorporate normal growth and development, adapt method and terminology of client instructions as it relates to the age and comprehension level of the client, and to ensure a safe environment - reflecting specific needs of the client and various age groups.

AGE

0	1	2	3	4	5

Proficiency Rating

Adults*
Application Agreement*
- I certify that the test was filled out to the best of my knowledge.
Signature*
Date*
First Name*
Last Name*
Applicant Email*
Applicant Phone*

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