Skills Checklist – Dialysis Tech Skills Checklist – Dialysis Tech Name First Last Phone Email EXPERIENCE* Rarely Some Experience Proficient Trainer / Preceptor N/A Acute/Inpatient Dialysis Chronic/Outpatient Dialysis Dialysis Home Care Pediatric Dialysis Patient and Family Education SET UP / INITIATE DIALYSIS TREATMENT* Rarely Some Experience Proficient Trainer / Preceptor N/A Bicarbonate Dialysate Conductivity Testing Priming Dialyzer Checks for Machine/Alarm Settings Prep Vascular Access Local/Topical Skin Anesthesia Collect Blood Specimens Machine set up w/Anticoagulant ASSESS PATIENT AND EQUIPMENT DURING DIALYSIS* Rarely Some Experience Proficient Trainer / Preceptor N/A Volume Status Vascular Access Function Arterial and Venous Blood Flow Rate Subjective Response to Treatment Management of Anticoagulation Conductivity Ultrafiltration Calculation Operation of Myron L. Meter Sequential Ultrafiltration/PUF Documentation of Dialysis Treatment MACHINE ALARM TROUBLESHOOTING PROCEDURES* Rarely Some Experience Proficient Trainer / Preceptor N/A Blood Leak Alarm Arterial Pressure Alarm Venous Pressure Alarm Conductivity Alarm High Temperature Alarm Air/Foam Detector Alarm Power Failure Alarm Blood Pump Alarm DISCONTINUE DIALYSIS* Fistula / Vein Graft Some Experience Proficient Trainer / Preceptor N/A LIDO Machine Return of Blood Post Treatment Access Care Equipment Clean Up Sterilization Procedures CARE OF PATIENT WITH* Rarely Some Experience Proficient Trainer / Preceptor N/A AV Fistula/AV Graft Peritoneal Dialysis Hemodialysis Tunneled/Non‐Tunneled catheter Fluid Overload Hypertension Hypotension Disequilibrium syndrome Hyperkalemia Seizures Muscle Cramps Pyrogenic Reaction Hemolysis Air Embolus Chest Pain Anemia Neuropathy Pericarditis Filter Blood Leak Cardiopulmonary Arrest OTHER – TYPES OF ELECTRONIC DOCUMENTATION:(if applicable) Age Group Experience* Rarely Some Experience Proficient Trainer / Preceptor N/A Newborn (birth – 30 days) Infant (30 days – 1 year) Toddler (1 – 3 years) Preschooler (3 – 5 years) School Age (5 – 12 years) Adolescents (12 – 18 years) Young Adults (18 – 39 years) Middle Adults (39-64 years) Older Adults (64+ years) Do you speak any languages other than English?* No If yes, enter languages above, separated by commas. Confirmation* I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education. Signature Date Date Format: MM slash DD slash YYYY