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IV Therapy RN
Infusion RN
Name
*
Full Name
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
Nonvascular Catheter Competencies
No Experience
Limited Experience
Experienced
Highly Skilled
Subcutaneous Insertion
Subcutaneous Removal
Peripheral Catheter Competencies
No Experience
Limited Experience
Experienced
Highly Skilled
Midline Catheter Insertion
Midline Catheter Removal
Peripheral - Short Catheter Insertion (over the needle)
Peripheral - Short Catheter Insertion (winged steel needle)
Peripheral - Short Catheter Removal (over the needle)
Peripheral - Short Catheter Removal (winged steel needle)
Central Vascular Access Device Competencies
No Experience
Limited Experience
Experienced
Highly Skilled
Nontunneled/Noncuffed Central Venous Access Catheter Removal
PICC Care and Access
PICC Removal
Port-a-Cath - Access
Port-a-Cath - Deaccess
Care and Maintenance Competencies
No Experience
Limited Experience
Experienced
Highly Skilled
Change of Administration Set
Conversion from Continous VAD to Intermittent Infusion
Conversion from Continous VAD to Continous Infusion
Dressing Application - Central Venous Access Device
Dressing Application - Intraspinal Access Device
Dressing Application - Nonvascular Access Device
Dressing Application - Peripheral Vascular Access Device
Flushing Using SASH Technique
Infusion Related Competencies
No Experience
Limited Experience
Experienced
Highly Skilled
Administration of Blood and Blood Products
Administration of Hypodermoclysis
Administration of Local Anesthesia via Subdermal Injection
Application of Local Anesthesia via Transdermal Analgesic
Application of Local Anesthesia via Sonification
Instillation of Fibrinolytic Agent to Restore Catheter Patency
Obtaining Blood Cultures via Vascular Access Device
Obtaining Blood via Central Venous Access Device
Obtaining blood via PICC
Phlebotomy via Venipuncture
Ultrasound and Modified Seldinger Technique (MST)
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