Dialysis Tech

Dialysis Tech

  • 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

    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
  • No ExperienceLimited ExperienceExperienceHighly Skilled
    Acute/Inpatient Dialysis
    Chronic/Outpatient Dialysis
    Dialysis Home Care
    Pediatric Dialysis
    Patient and Family Education
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Bicarbonate Dialysate
    Conductivity Testing
    Priming Dialyzer
    Checks for Machine/Alarm Settings
    Prep Vascular Access
    Local/Topical Skin Anesthesia
    Machine set up w/Anticoagulant
    Collect Blood Specimens
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Volume Status
    Vascular Access Function
    Arterial and Venous
    Blood Flow Rate
    Subjective Response to Treatment
    Management of Anticoagulation
    Ultrafiltration Calculation
    Operation of Myron L. Meter
    Sequential Ultrafiltration/PUF
    Documentation of Dialysis Treatment
  • No ExperienceLimited ExperienceExperiencedHighly skilled
    Blood Leak Alarm
    Arterial Pressure Alarm
    Venous Pressure Alarm
    Conductivity Alarm
    High temperature Alarm
    Air/foam Detector Alarm
    Power Failure Alarm
    Blood Pump Alarm
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Fistula/Vein Graft
    Return of Blood
    Post Treatment Access Care
    Equipment Clean Up
    Sterilization Procedures
    AV Fistula/AV Graft
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Peritoneal Dialysis
    Tunneled/Non-Tunneled Catheter
    Fluid Overload
    Disequilibrium Syndrome
    Muscle Cramps
    Pyrogenic Reaction
    Air Embolus
    Chest Pain
    Filter blood leak
    Cardiopulmonary arrest
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Newborn/Neonate (birth to 30 days)
    Infant (1 month to 1 year)
    Toddler (1 year to 3 years)
    Preschooler (3 years to 5 years)
    School Age Child (5 years to 12 years)
    Adolescents (12 years to 18 years)
    Young Adults (18 years to 39 years)
    Middle Adults (39 to 64 years)
    Geriatric Adults (65+ years)
  • By signing below, I attest that the information contained above is accurate to the best of my knowledge and that I am the individual completing this form. I further authorize the Company to release this Qualification List to the Client facilities in accordance with the consideration of employment as a Healthcare Professional with those facilities.

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