SELF EVALUATION
SPECIAL PROCEDURES/CARDIAC CATH
SKILLS PROFICIENCY CHECKLIST

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     Last Name: 
    First Name: 
Middle Initial: 

      		
    

  



DIRECTIONS: Place
an x in the box that best describes your level of
proficiency for each of the skills presented.


LEVELS OF PROFICIENCY
  KEY:

  

    

      
      
    

    

      HP =
      
        
Highly Proficient.

        Extensively experienced; able to supervise and/or train others.

      
      SE =
      
        
Some Experience.

        Need review and assistance or supervision.

    

    

      VE =
      
        
Very Experienced.

        Can perform well without assistance or supervision.

      
      NE =
      No Experience.
    

    

      EX =
      
        
Experienced.

        Competent; can perform independently; may need initial review or
        supervision.

      
      
      
    

  


  

    

      
    

    

      SPECIAL PROCEDURES:
      HP
      VE
      EX
      SE
      NE
      
    

    

      Selective Angiography
      
      
      
      
      
      
    

    

      Carotid Arteriogram
      
      
      
      
      
      
    

    

      Brachial Arteriogram
      
      
      
      
      
      
    

    

      Arch Arteriogram
      
      
      
      
      
      
    

    

      Renal Arteriogram
      
      
      
      
      
      
    

    

      Femoral Arteriogram
      
      
      
      
      
      
    

    

      Abdominal Arteriogram
      
      
      
      
      
      
    

    

      Mesenteric Arteriogram
      
      
      
      
      
      
    

    

      Peripheral Angioplasty
      
      
      
      
      
      
    

    

      CARDIAC CATH LAB:
      HP
      VE
      EX
      SE
      NE
       
    

    

      Pulmonary Arteriogram
      
      
      
      
      
       
    

    

      Athenoskimy
      
      
      
      
      
       
    

    

      Balloon Pumps
      
      
      
      
      
       
    

    

      External Pacemakers
      
      
      
      
      
       
    

    

      Internal Pacemakers
      
      
      
      
      
       
    

    

      Coronary Angioplasty
      
      
      
      
      
       
    

    

      
        Other: 
      
      
      
      
      
       
    

    

      
        Other: 

  


        
      
      
      
      
      
       
    

    

      
        Other: 

  


        
      
      
      
      
      
       
    

  




  

  
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