SELF EVALUATION
ULTRASOUND DIAGNOSTIC
SKILLS PROFICIENCY CHECKLIST

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     Last Name: 
    First Name: 
Middle Initial:  
Years Experience:

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 = SE = Some Experience;
Need review and assistance or supervision.
VE = Very Experienced;
Can perform well, without assistance or supervision.		 NE = NE = No Experience.
EX = Experienced; Competent;
Can perform independently;
May need initial review or supervision.		    
PROFICIENCY LEVEL
 GENERAL: HP VE EX SE NE
Abdomen
Appendix
Gall Bladder
Renal
Biliary tree
Pancreas
Liver
Aorta
Kidneys
Spleen
Adrenals
Paracentisis
Thorocentisis
Doppler of listed areas
Other
Other
OBSTETRICS AND
GYNECOLOGY:		 HP VE EX SE NE
1st - 3rd Trimester Pregnancy
Level I
Stomach
Heart
Kidneys
Diaphragm Bladder
Cerebellum
Ventricles
Atria and Nuchal Fold
Level II
Fingers and Toes
Bone Lengths
Nose and Lips
Interorbital Measurements
Intraorbital Measurements
High Risk
Amniocentesis
Neonatal Heads
Uterus
Ovaries
Adnexa
Transvaginal
Transabdominal Pelvic
Doppler of listed areas
Other
Other
SMALL PARTS: HP VE EX SE NE
Thyroids
Breasts
Testicles
Scrotum
Superficial Masses
Biopsies
Doppler of listed areas
Other 
Submitted by:      Date:

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