Skills Checklist – Endoscopy

Skills Checklist – Endoscopy

• Name
  
  First
  
  Last
• Phone
• Email
  
• PROCEDURES*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Assist with EGD’s
  Assist with Endoscopic Ultrasound
  Assist with Active GI Bleed
  Cautery Devices
  Assist with Manometry Studies
  Assist with Variceal Banding

• PROCEDURES – ASSIST WITH ESOPHAGEAL DILATATIONS:*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  – Balloon
  – Other types
  Assist with Sclerotherapy
  Assist with TEE
  Assist with Bronchoscopy
  Assist with Colonscopy
  Assist with Polypectomy
  Assist with ERCP’s
  Assist with PEG placements
  Assist with Collection of Hot & Cold Bx’s
  Specimen Collection & Labeling
  Apply External Abdominal Pressure to assist with Scope Movement
  Monitoring of Conscious Sedation

• PRE/POST PROCEDURE*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Knowledge of Sedation Reversal Agents
  O2 Administration
  Pulse Oximetry
  Scope Cleaning
  Set-up of Scopes & Video Equipment
  Obtain IV Access
  Pre-procedure Checklist
  Pre-procedure Teaching
  Monitor EKG
  Monitor O2 sats
  Monitor VS
  Use of Sedation Recovery Scale
  Airway Management
  Assess GI Statue Post-procedure
  Assess for Gag Reflex Post EGD
  Perform Post Procedure Teaching

• PRE/POST PROCEDURE – MEDICATIONS:*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Antibiotics
  Insulin
  Conscious Sedations Medications
  Sedation Reversal Agents

• EQUIPMENT*
  

  	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
  Computer Charting Systems

• Do you speak any languages other than English?*
  • No

  If yes, enter languages above, separated by commas.

• 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)

• 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