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EP RN
EP RN
Name
First
Last
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
Experience With Ages
No Experience
Limited Experience
Experienced
Highly Skilled
Newborn/neonate (Birth-30 days)
Infant (1 mo-1 yr)
Toddler (1-3 yrs)
Preschooler (3-5 yrs)
School age child (5-12 yrs)
Adolescents (12-18 yrs)
Young adults (18-39 yrs)
Middle adults (29-64 yrs)
Older adults (64-79 yrs)
Elderly adults (79+ yrs)
General Skills
No Experience
Limited Experience
Experienced
Highly Skilled
Standard precautions
Isolation precautions
Pediatric respiratory/cardiac arrest
Adult respiratory/cardiac arrest
Crash carts
Defibrillators
Care of patient in restraints
Pain management
Automated med dispensing systems
Care planning and discharge planning
Patient/family education
Electronic documentation
Patient head to toe assessent
Peripheral IV insertion, care, and maintenance
Medications
No Experience
Limited Experience
Experienced
Highly Skilled
Calculate mcg/min and mcg/kg/min
Titrating medications
Isuprel
Procainamide
Esmolol
Adenosine
Amiodarone
Antibiotics
Analgesics
Sedatives
Assessment and Monitoring
No Experience
Limited Experience
Experienced
Highly Skilled
Lead placement
Basic 12 lead EKG interpretation
Doppler
Blood pressure - Invasive and noninvasive
Cardiac rhythm interpretation
Hemodynamic monitoring
No Experience
Limited Experience
Experienced
Highly Skilled
Art line
Swan ganz
Waveform assessment
General lab work interpretation
ABG interpretation
Cardiac enzyme interpretation
Chemistry interpretation
Care and maintenance
No Experience
Limited Experience
Experienced
Highly Skilled
Central venous acces device
Arterial line
Swan ganz
IABP
Sheaths
Removal of sheath
Manual pressure hold
C-Clamp
FemStopo
VasoSeal, AngioSeal, PerClose
Hematoma recognition/management
Procedure/Equipment
No Experience
Limited Experience
Experienced
Highly Skilled
Scrup EP procedures
Circulate EP procedures
Monitor EP procedures
Ablation (atrial/ventricular)
Velocity mapping
Cart/mapping
Rhythmia mapping
Bloom stimulator
Micropace Ep-4
Diagnostic catheters
Bi-V
Stereotaxis
AICD placement
Bovie
PPM
Baylis
Temporary pacemaker
Peak plasma blade
Cardioversion
Internal cardioversion catheters/AICD testing
NIPS procedure
Pericardiocentesis
Demonstrate proper preservation of tissue specimen for lead extractions
ACT machine
Lead extractions - Spectranetics laser
Device implants
Ablation equipment (Stockert, Maestro, Cool flow, Tactisys, etc.)
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