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Interventional Radiology
Interventional Radiology
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
Age
No Experience
Limited Experience
Experienced
Highly Skilled
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)
General Skills
No Experience
Limited Experience
Experienced
Highly Skilled
Standard Precautions
Isolation Precautions
Sterile Field
Pediatric Respiratory/Cardiac Arrest
Adult Respiratory/Cardiac Arrest
Crash Carts
Defibrillators
Adult Ventilator Management
Care of Patient in Restraints
Pain Management
Automated Med Dispensing Systems
Care Planning & Discharge Planning
Patient/Family Education
Electronic Documentation
Patient Head to Toe Examination
Pulse Oximetry
Use of Portable Monitors
Cardiac Monitoring
EKG Interpretation (Basic)
Airway Management
Oxygen Delivery Devices
Care of the Patient Under Neutropenic or Bleeding Precautions
End of Life Care
Circulate-Assist with Insertion /Removal/Repair of:
No Experience
Limited Experience
Experienced
Highly Skilled
Hickman CVL
Broviac CVL
Subclavian CVL
Jugular CVL
Groshong CVL
PICC
Implantable Ports/Infusaport/Mediport
Femoral Line
Hemodialysis Catheter
Declotting Central Venous Lines
Scrub-Assist with Insertion/Removal/Repair of:
No Experience
Limited Experience
Experienced
Highly Skilled
Hickman CVL
Broviac CVL
Subclavian CVL
Jugular CVL
Groshong CVL
PICC
Implantable Ports/Infusaport/Mediport
Hemodialysis Catheter
Declotting
TIPPS
Angiography
Cerebral Angiogram
Spinal Angiogram
Ultrasound or CT Guided Biopsy
Uterine Fibroid Embolization
Vertebroplasty
Myelogram
Lumbar Puncture
Scrub the Following Procedures
No Experience
Limited Experience
Experienced
Highly Skilled
Nephrostomy Tubes
G-tube
PEG Tube
Y90 Peripherals
Renals
Coiling
Neuro Intervention
Neuro Angiography
Carotid Intervention
Carotid Angio
Pedal Access
Laser
Snare
Thrombectomy/ Thrombdysis
Nephroureteral Stents
Epistaxis Embolization
Angiography
Spinal Angiogram
Ultrasound or CT Guided Biopsy
Uterine Fibroid Embolization
Vertebroplasty/ Kyphoplasty
Myelogram
Lumbar Puncture
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