Dialysis Competency Self Assessment

Directions
Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional.

Experience
1 No Experience 2 Some Experience (Requires Assistance) 3 Experienced (Performs without Assistance) 4 Very Experienced (Performs Well)

________________________________________________________________________________________________________ Print Name Last 4 Digits of SS# Date General Skills

Advanced directives Patient/family teaching Lift/ transfer devices Specialty beds Restrictive devices (restraints) End of life care/palliative care Wound assessment & care Automated medication dispensing Bar coding for medication administration Diabetic care and education Blood Glucose Monitoring (BGM) Computerized Charting Cerner EPIC Eclipsys McKesson Meditech National Patient Safety Goals Accurate patient identification Effective communication Interpretation & communication of lab values Medication administration Labeling (medications & specimens) Medication reconciliation Anticoagulation therapy Pain assessment & management Use of PCA (IV, intrathecal,epidural) Infection control Universal precautions Isolation Minimize risk falls
2012 Cross Country Healthcare, Inc. Rev. 07/12

Experience
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

F0018 Dialysis 1 of 4

Experience
1 No Experience 2 Some Experience (Requires Assistance) 3 Experienced (Performs without Assistance)

Initials ___________ General Skills - cont.

Prevention of presure ulcers Use of rapid response teams Experience Acute/inpatient dialysis Chronic outpatient dialysis Dialysis home care Pediatric dialysis Apheresis Plasmapheresis Peritoneal Dialysis Continuous Ambulatory Peritonial Dialysis (CAPD) Continuous Cycled Peritoneal Dialysis (CCPD) Types of Dialysis Continuous Arteriovenous Hemofiltration (CAVH) Continuous Venovenous Hemofiltration (CVVH) Continuous Arteriovenous Hemodialysis (CAVHD) Continuous Venovenous Hemodialysis (CVVHD) Dialysis Equipment Althin Cobe Fresenius Baxter Prisma B. Braun Dialog Set Up/Initiate Dialysis Set up/appropriate equipment Bicarbonate dialysate Conductivity & pH testing - chlorine/chloramine Priming the dialyzer Checks for machine/alarm settings Prep vascular access Fistula or graft Collect blood specimen Assessment of Equipment & Patient During Dialysis Predialysis RN assessment Volume assessment Blood flow rates Subjective assessment of response to treatment Conductivity meters
2012 Cross Country Healthcare, Inc. Rev. 07/12

4 Very Experienced (Performs Well)

Frequency
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Experience
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

F0018 Dialysis 2 of 4

Experience
1 No Experience 2 Some Experience (Requires Assistance) 3 Experienced (Performs without Assistance)

Initials ___________ General Skills - cont.

Ultra filtration calculation Ultra filtration modeling Sodium modeling Knowledge of peritoneal dialysis solutions Administration of IV push medication/IV pump medications Levocarnitine Epogen/aranesp Vitamin D derivatives Iron replacement Administration of mannitol/albumin/23.4% NaCL Administration of anti-infectives Sequential ultra filtration/PUF/DUF Machine/alarm troubleshooting Management of a Patient with: Cardiac arrest Pericarditis Air emboli Chest pain Filter blood leak Pyrogenic reactions Disequilibrium syndrome Hypotension/hypertension Muscle cramps Catheter declotting protocols Anemia Neuropathy Hemolysis Infiltration of an AV access Discontinuation of Dialysis Treatment Retransfusion procedure Dialysis catheter procedure Fistula/graft procedure Equipment clean up & sterilization Biohazard waste procedures

4 Very Experienced (Performs Well)

Experience
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Skilled Nursing Care

Charge nurse/management experience Cardiac monitoring Airway management
2012 Cross Country Healthcare, Inc. Rev. 07/12

Experience
1 1 1 2 2 2 3 3 3 4 4 4

F0018 Dialysis 3 of 4

Experience
1 No Experience 2 Some Experience (Requires Assistance) 3 Experienced (Performs without Assistance)

Initials ___________ Skilled Nursing Care - cont.

Oxygen therapy Oral/nasotracheal suctioning Pulse oximetry Start & maintain peripheral IVs Assessment of circulation/peripheral pulses Foley catheter insertion/maintenance NG tube insertion/maintenance Administration of blood/blood products Management of fluid/electrolyte balance Seizure precautions Knowledge of lab values for ESRD patients Knowledge of ESRD dietary recommendations

4 Very Experienced (Performs Well)

Experience
1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4

Age Specific Competencies

Newborn/neonate (birth-30 days) Infant (31 days-1 years) Toddler (2-3 years) Preschool (ages 4-5 years) School age (ages 6-12 years) Adolescents (ages 13-21 years) Young adult (ages 22-39 years) Adults (ages 40-64 years) Older adult (ages 65-79 years) Elderly (80+ years) 1 1 1 1 1 1 1 1 1 1

Experience
2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4

Please list any Additional Skills:

1. 3. Additional training: 1. 3. Additional equipment: 1. 3. 2. 4. 2. 4. 2. 4.

Fax to: 1-888-298-3146 The information on this and all preceding pages is true and correct. ___________________________________________________________________________________________________ Signature Date
F0018 Dialysis 4 of 4

2012 Cross Country Healthcare, Inc. Rev. 07/12