Monitor Technician Checklist

NAME

LAST 4 OF SSN

Date of application

E-MAIL

I hereby certify that ALL information I have provided 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.

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.

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Experience In The Following Setting(s)	Rating Stars (Click)	1	2	3	4
Telemetry Unit (located on the unit)
Remote Telemetry Office
Patient/Equipment Preparation	Rating Stars (Click)	1	2	3	4
Skin prep
Lead Placement - 3 Lead
Lead Placement - 5 Lead
Set up MCL1
Set up Lead II
Set up 12 Lead ECG
Interpret The Following Rhythms	Rating Stars (Click)	1	2	3	4
Normal Sinus Rhythm
Sinus Bradycardia/Sinus Tachycardia
Premature Atrial Contractions
Atrial Flutter
Atrial Fibrillation
Junctional Rhythms
PVC - Unifocal/Multifocal
PVC- Bigeminy/Trigeminy/Coupling
Ventricular Tachycardia
Ventricular Fibrillation
1st Degree Heart Block
2nd Degree Heart Block Type I
2nd Degree Heart Block Type II
3rd Degree Heart Block
Sinus Arrest
Monitoring System Used	Rating Stars (Click)	1	2	3	4
GE
Philips
Spacelabs
Miscellaneous	Rating Stars (Click)	1	2	3	4
Cardiac Arrest Protocol
Computerized Charting
EMR	Rating Stars (Click)	1	2	3	4
PIC
Cerner
Eclipsys
McKesson
Meditech
Computerized Physician Order Entry
Bar Coding for Medication Administration
Age Specific Competencies	Rating Stars (Click)	1	2	3	4
Newborn/Neonate (birth to 30 days)
Infant (30 days - 1 year)
Toddler (1 - 3 years)
Preschooler (3 years to 5 years)
School age children (5 - 12 years)
Adolescents (12 - 18 years)
Young adults (18 - 39 years)
Middle Adults (39 to 64 years)
Older adults (64+ years)