Self-Assessment Form for ICU

Prerequisite for PGY2 and above

Yes No

Name: _________________________ Program: ___________________

Completed ACLS course within last 3 years. These are expected PRIOR to the ICU rotation. Basic Competencies Yes No Can do a history and physical. Yes No Have an approach to interpretation of an electrocardiogram. Yes No Have an approach to interpretation of a chest radiograph. Yes No Have an approach to interpretation of blood gases. Yes No Can present a case in an organized fashion. Yes No Can develop a problem list. Yes No Know the algorithms of ACLS for resuscitation. Yes No Can interpret an electrocardiogram and diagnose a myocardial infarction. Yes No Can identify common rhythm disturbances from a electrocardiogram. Note: If you cannot answer YES to ALL of the above you should improve your skills BEFORE coming to ICU. Discuss the issue with your program director! Yes No Did Medicine CTU during PGY1 Yes No Did ICU rotation during PGY1

Directions for completion of Advanced Competencies Section of Self Assessment Form

Leave all blank if you do not have this competency. Darken the first square if you have only rudimentary knowledge in this area. Darken first two if you are convinced you have adequate knowledge but lack experience. Darken all squares if you feel you have adequate knowledge and experience.

Advanced Competencies

Many of these are expected to develop DURING the ICU rotations

Can classify shock and outline hemodynamic patterns Can manage the initial stabilization and assessment of a critically ill patient Can maintain a clear airway Knows indications for and can perform a tracheal intubation Knows methods of confirming endotracheal tube position Knows indications for and methods of providing ventilatory support Can provide ventilator orders for most patients Knows indications and techniques of arterial line insertion Knows indications and techniques of central line insertion Can be team leader for a Code Blue Can provide emergency management of acute respiratory failure Can provide emergency management of tachycardia Can provide emergency management of hypertension Can provide emergency management of hypotension Can provide emergency management of myocardial infarction Can diagnose and treat acid base disorders Can diagnose and treat Acute Lung Injury (ARDS) Can manage an epicardial pacemaker Insert and manage a transvenous pacemaker Knows principles of ICP management and monitoring Rationally select inotropes and vasodilators
Send a copy of this form to Maryanne Henderson GE706 HSC (Fax 787-3069) before the rotation starts!!!