Endoscopy Checklist
  Endoscopy Checklist
   NAME    
   LAST 4 OF SSN      
   DATE    
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.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

 
       
Rating Stars (Click) Procedures 1 2 3 4  
Assist with EGD’s  
Assist with endoscopic ultrasound  
Assist with active GI bleed  
Cautery devices  
Assist with manometry studies  
Assist with variceal banding  
Assist with esophageal dilatations  
Assist with esophageal ballooning  
Assist with scelrotherapy  
Assist with TEE  
Assist with bronchoscopy  
Assist with colonoscopy  
Assist with polypectomy  
Assist with ERCP’s  
Assist with PEG placements  
Assist with liver BX  
Assist with collection of hot & cold BX’s  
Specimen collection & labeling  
Set up of scopes & video equipment  
Apply external abdominal pressure to assist with scope movement  
Scope cleaning  
Assist with mobile cases, ICU, ER, etc.  
Radiation safety  
Automated Medication Dispensing System, Pyxis, Omnicell, or other  
Takes call for emergency cases  
National Patient Safety Goals  
Awareness of HCAHPS  
Accurate patient identification  
Effective communication  
Interpretation & communication of lab values  
Medication administration  
Anticoagulation therapy  
Monitoring conscious sedation  
Pain assessment & management  
Infection control  
Universal precautions  
Isolation  
Minimize risk for falls  
Prevention of pressure ulcers  
Use of rapid response teams  
  Administer Conscious Sedation  
Fentanyl  
Propofol  
Demerol  
Presedex  
Versed  
Reversal agents  
  Pre Procedure  
Pre procedure phone calls  
Electronic documentation  
Patient assessment  
Colon prep or re-prep  
Pre procedure checklist/consent  
IV start, med admin  
  Post Procedure  
Assess for air movement post colonoscopy  
Assess for pain  
Assess for bowel sounds  
Assess for gag reflex post EGD  
Assess for gag reflex post bronchoscopy  
Recover from MAC  
Recover from (moderate) conscious sedation  
Discharge outpatients to home  
Post procedure phone calls  
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Newborn/neonate (birth-30 days)  
Infant (31 days-1 year)  
Toddler (ages 2-3 years)  
Preschool (ages 4-5 years)  
School age (ages 6-12 years)  
Adolescent (ages 13-21 years)  
Young adult (ages 22-39 years)  
Adult (ages 40-64 years)  
Older adult (ages 65-79 years)  
Elderly (ages 80+ years)