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Competency Checklist

Date: Employee Name: Preceptor/Evaluators Name Competency: Code Blue, Rapid Response and Crash Cart

INDICATORS OF PERFORMANCE LEVEL SUMMARY

How Met Level of Competency

O Direct Observation/Return Demonstration 1 Below expected standards V Verbalization/Discussion 2 Fully meets standards T Test 3 Well above standards. May precept peers NA Not applicable

If overall performance or competency is rated below the minimum competency level of 2, that performance or competency must be reassessed within 30 days of this review.

The employee demonstrates skills and competence in the following: How Met

Level of Competency

1 2 3

Evaluated by:

Location of crash cart and O2 tank Locate ambu bag, mask and flowmeter Know how to attach flowmeter to wall Locate Defribrillator: Turn it on and ensure recorder is working properly with paper available

Demonstrate knowledge of testing defibrillators batteries Locate conductive gel and EKG electrodes on cart Backboard location and placement Able to locate suction setup (regulator, canister, connection tubing and suction catheters) Able to locate intubation supplies on cart Know how to attach blade to Laryngoscope. Ensure that the light is working and extra bulbs are available

Locate endotracheal tubes (sizes 6.5, 7.0, 7.5, 8.0) and stillettes , Locate IV supplies and medications Locate adapater for emergency drugs to use with needless systems Be familiar with the first line of medications (Lidocaine, epinephrine, atropine, HCO3, etc.)

Locate external pacer pads and cable on cart o Employee is competent to perform the above tasks independently and without supervision o Employees level of competence is below 2. Reassess competency on:_______________________________________ Employees Signature Evaluators Signature