Gastroenterology/Endoscopy Skills Checklist Date:* Name: (First, MI, Last)* Email Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledPROCEDURES, ASSIST OR KNOWLEDGE OFAnoscopy* 0 1 2 3 Bronchoscopy* 0 1 2 3 Colonoscopy* 0 1 2 3 EGD* 0 1 2 3 ERCP* 0 1 2 3 Flexible Sigmoidoscopy* 0 1 2 3 IV Drip* 0 1 2 3 Proper Assesment and Documentation of Conscious Sedation Record* 0 1 2 3 Rigid Protoscopy* 0 1 2 3 Sphincterotomy* 0 1 2 3 Accessory EquipmentCytology Brushes* 0 1 2 3 Decompression Tubes* 0 1 2 3 Dilators: Balloon* 0 1 2 3 Dilators : Maloney* 0 1 2 3 Dilators : Savory* 0 1 2 3 Foreceps* 0 1 2 3 Foreign Body Equipment* 0 1 2 3 Polyp Snares* 0 1 2 3 Valley Lab BX* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledBLEEDER CART EQUIPMENTBicap Unit* 0 1 2 3 Code Blue Lavage Kit* 0 1 2 3 Endo Pump* 0 1 2 3 Esophageal Banding* 0 1 2 3 Gold Probe / Injector Needle* 0 1 2 3 Scero Needles and Meds* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledGASTRO - INTESTINAL FEEDING TUBESJejunal feeding tube* 0 1 2 3 Naso-Enteric Tube* 0 1 2 3 Peg Insertion Equipment* 0 1 2 3 Replacement Gastrostomy Buttons* 0 1 2 3 Replacement Gastrostomy Tubes* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledERCPEquipment and Stock* 0 1 2 3 Papillatomy* 0 1 2 3 Som Procedure* 0 1 2 3 Stent Placement* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledSPECIMEN COLLECTIONBiopsies* 0 1 2 3 Cytology* 0 1 2 3 Immuno Suppressed Protocol* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledManometry and Diagnostic Testing24 Hour PH Ambulatory Study* 0 1 2 3 Esophogeal Manometry* 0 1 2 3 Liver BX* 0 1 2 3 Paracentesis* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledPEDIATRIC PROCEDURESPediatric Peg Cart* 0 1 2 3 Proper EGD Scopes According to Age* 0 1 2 3 Specific Equipment for Pediatric Scopes* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledCLEANINGProper Scope Cleaning* 0 1 2 3 Proper Use Of Scope Washers* 0 1 2 3 Storing Scopes* 0 1 2 3 Use Of Leak Tester* 0 1 2 3 BLS MM slash DD slash YYYY ACLS MM slash DD slash YYYY Telemetry Certificate MM slash DD slash YYYY ONS Chemo/Biotherapy Certification MM slash DD slash YYYY Other Chemo Certification MM slash DD slash YYYY Areas of Expertise:Consent* By submitting this form, I agree to all terms and conditions and agree to authorize consent NameThis field is for validation purposes and should be left unchanged.
