Skills Checklist – Endoscopy

Skills Checklist - Endoscopy

Name
First Last
Phone
Email

PROCEDURES*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Assist with EGD's
Assist with Endoscopic Ultrasound
Assist with Active GI Bleed
Cautery Devices
Assist with Manometry Studies
Assist with Variceal Banding

PROCEDURES - ASSIST WITH ESOPHAGEAL DILATATIONS:*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
- Balloon
- Other types
Assist with Sclerotherapy
Assist with TEE
Assist with Bronchoscopy
Assist with Colonscopy
Assist with Polypectomy
Assist with ERCP's
Assist with PEG placements
Assist with Collection of Hot & Cold Bx's
Specimen Collection & Labeling
Apply External Abdominal Pressure to assist with Scope Movement
Monitoring of Conscious Sedation

PRE/POST PROCEDURE*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Knowledge of Sedation Reversal Agents
O2 Administration
Pulse Oximetry
Scope Cleaning
Set-up of Scopes & Video Equipment
Obtain IV Access
Pre-procedure Checklist
Pre-procedure Teaching
Monitor EKG
Monitor O2 sats
Monitor VS
Use of Sedation Recovery Scale
Airway Management
Assess GI Statue Post-procedure
Assess for Gag Reflex Post EGD
Perform Post Procedure Teaching

PRE/POST PROCEDURE - MEDICATIONS:*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Antibiotics
Insulin
Conscious Sedations Medications
Sedation Reversal Agents
EQUIPMENT*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Computer Charting Systems
Do you speak any languages other than English?*
- No
If yes, enter languages above, separated by commas.

Age Group Experience*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
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)

Confirmation*
- I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
Signature
Date
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