Anesthesia Tech

Name
First Last
Email
Phone
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale:
No Experience
Theory or observation only during the past 12 months

Limited Experience
Performed less than 12 times within the past 12 months and may need a review

Experienced
Performed at least once per month within the past 12 months and may need minimal assistance

Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient

Age

	No Experience	Limited Experience	Experienced	Highly Skilled
Newborn/Neonate (birth to 30 days)
Infant (31 days to 12 months)
Toddler/Preschool (13 months to 5 years)
School Age Child/adolescent (6 years to 18 years)
Young Adults/Middle Adult (19 years to 64 years)
Older Adults/Elderly (65+ years)

General Knowledge

	No Experience	Limited Experience	Experienced	Highly Skilled
Proper identification of patient using at least 2 identifiers
Proper identification/labeling of all lab or specimen results
Pre-procedural time-out process
Demonstrate application of all monitoring devices
Understanding of scope of practice and limitations as a certified anesthesia technician
Prioritize tasks related to role and function
Delegating responsibilities to other team members of anesthesia team
Knowledge of professional standards to uphold patient rights and confidentiality
Knowledge of "Do Not Use Abbreviations"
Do you have charge/supervisor experience?
Knowledge of current Joint Commission National Patient Safety Goals
Knowledge/familiarity with HCAHPS scores
Basic life support
Purpose, use and care of physiological monitors relating to the administration of anesthesia
Biologic hazards, infection control, and standard precautions
Fire, electrical, laser and explosion hazards in the operating room and other anesthesia related areas
Storage, use and safe handling of bulk and cylinder gases
Structure, function and care of all components of anesthesia delivery systems
Sterile technique and the principals of aseptic practice
Usage of common anesthetic gases
Type and indications for local, monitored anesthesia care (MAC), regional and general anesthesia
Assists the licensed anesthesia providers in various settings
Performs duties under the direct supervision of a licensed anesthesia provider and/or Registered Nurse (RN)
Provides support for routine surgical cases by assisting in the preparation and maintenance of patient equipment and anesthesia delivery systems before, during and after anesthesia
Performs first level maintenance on anesthesia equipment
Cleans, sterilizes, disinfects, stocks, orders and maintains the routine anesthesia equipment and supplies
Principles of purchasing and supply levels
Communication skills
Ability to troubleshoot delivery systems, monitors, and ancillary devices
Participate in Quality Assurance
Maintain quality control records for anesthesia department
Use of electronic medical record charting
Participate in continuing education development for the certified anesthesia technician
Implement safety procedures and guidelines for fire safety and infection control
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