SELF EVALUATION
SPECIAL PROCEDURES/CARDIAC CATH
SKILLS PROFICIENCY CHECKLIST

Print this form and fax or mail:
Fax to: (505) 797-3822
Mail to: 5150 San Francisco RD NE, Albuquerque, NM 87109 
NAME: _____________________________________
      Last           First          M.I.
 

    		
  





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
      
      CARDIAC CATH LAB:
      HP
      VE
      EX
      SE
      NE
    

    

      Selective Angiography
      
      
      
      
      
      
      Pulmonary Arteriogram
      
      
      
      
      
    

    

      Carotid Arteriogram
      
      
      
      
      
      
      Athenoskimy
      
      
      
      
      
    

    

      Brachial Arteriogram
      
      
      
      
      
      
      Balloon Pumps
      
      
      
      
      
    

    

      Arch Arteriogram
      
      
      
      
      
      
      External Pacemakers
      
      
      
      
      
    

    

      Renal Arteriogram
      
      
      
      
      
      
      Internal Pacemakers
      
      
      
      
      
    

    

      Femoral Arteriogram
      
      
      
      
      
      
      Coronary Angioplasty
      
      
      
      
      
    

    

      Abdominal Arteriogram
      
      
      
      
      
      
      
        
Other: ________________________________________

        		
    

    

      Mesenteric Arteriogram
      
      
      
      
      
      
      
        
Other: ________________________________________

        		
    

    

      Peripheral Angioplasty
      
      
      
      
      
      
      
        
Other: ________________________________________

        		
    

  




  

  
Signature: ___________________________     Date: _________________







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