RN - IV Therapy/Infusion Skills Checklist

RN - IV Therapy/Infusion All the fields are mandatory

Name

Telephone (999-999-9999)

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Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency : -	1 = Never Performed	2 = Limited Experience	3 = Comfortable Performing	4 = Proficient
Frequency : -	1 = Never	2 = Sometimes	3 = Often	4 = Always

Infant (Birth to 1 year)

1

2

3

4

1

2

3

4

Toddler (1–3 years)

1

2

3

4

1

2

3

4

Pre-school (3–6 years)

1

2

3

4

1

2

3

4

School Age (6–12 years)

1

2

3

4

1

2

3

4

Adolescent (12–18 years)

1

2

3

4

1

2

3

4

Young Adult (18–30 years)

1

2

3

4

1

2

3

4

Mature Adult (30–60 years)

1

2

3

4

1

2

3

4

Elderly (>60 years)

1

2

3

4

1

2

3

4

Initiation/Insertion of IV Line

1

2

3

4

1

2

3

4

Regulate/Maintain IV Line

1

2

3

4

1

2

3

4

Troubleshoot slow/occluded IV Line

1

2

3

4

1

2

3

4

D/C peripheral IV Line

1

2

3

4

1

2

3

4

Manage complications of peripheral IV Line

1

2

3

4

1

2

3

4

Insertion of PICC Line

1

2

3

4

1

2

3

4

Maintain PICC Line

1

2

3

4

1

2

3

4

Confirmation of PICC Line placement via X-ray

1

2

3

4

1

2

3

4

Administer medications through PICC Line

1

2

3

4

1

2

3

4

Draw blood from PICC Line

1

2

3

4

1

2

3

4

D/C PICC Line

1

2

3

4

1

2

3

4

Assist provider with CVC placement/insertion

1

2

3

4

1

2

3

4

CVC tray set-up

1

2

3

4

1

2

3

4

CVC line confirmation via X-ray

1

2

3

4

1

2

3

4

Maintain CVC line

1

2

3

4

1

2

3

4

CVC dressing change

1

2

3

4

1

2

3

4

Manage CVC infusions

1

2

3

4

1

2

3

4

Draw blood from CVC line

1

2

3

4

1

2

3

4

D/C CVC line

1

2

3

4

1

2

3

4

Access implanted ports

1

2

3

4

1

2

3

4

Flushing of implanted ports

1

2

3

4

1

2

3

4

Draw blood from implanted ports

1

2

3

4

1

2

3

4

Dressing changes for implanted ports

1

2

3

4

1

2

3

4

Deaccess implanted ports

1

2

3

4

1

2

3

4

Maintain aseptic technique

1

2

3

4

1

2

3

4

Management of tunneled CVC
(e.g., Hickman, Broviac)

1

2

3

4

1

2

3

4

Management of Cordis IV catheter

1

2

3

4

1

2

3

4

Management of Groshong catheter

1

2

3

4

1

2

3

4

Line declotting

1

2

3

4

1

2

3

4

Saline/Heparin lock management

1

2

3

4

1

2

3

4

Administration of blood products

1

2

3

4

1

2

3

4

Years Experience in Clinical Specialty :

Most recent facility worked at :

I hereby certify that ALL information I have provided to Clover Health Services, on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.