Name: ________________________________________ Date: ____________________________
Skill: Emergency Preparedness
Steps Completed Comments
1. Assesses if a medical emergency exists: physical
assessment (patient responsiveness, LOC, vitals);
historical assessment (diabetes, autonomic neuropathy,
hypotensive episodes).
2. Identifies correct pathway cardiac rehab emergency
treatment algorithm.
3. Demonstrates ventilation technique via Resusci
mask.
4. Demonstrates O2 to ambu bag and nasal cannula
hook-up.
5. Demonstrates fitting patient with nasal cannula.
6. Performs BLS ABCs and one cycle of rescue
breathing and cardiac compressions.
7. Identifies team code number to call.
8. Demonstrates technique for transferring patient from
telemetry to defibrillator leads, selects limb and
augmented lead positions, runs an ECG strip.
9. Transports team cart and gurney from exam room to
exercise area.
10. Identifies team cart components: emergency drug
box, phase IV solutions, IV start sets, pulse oximeter.
11. Demonstrates: placement of conductive defib pads
on the chest wall, placement and pressure on the defib
paddles, and the correct sequence of ACLS
defibrillation shocks.
12. Demonstrates technique for transferring patient to
gurney and transporting patient to exam room or ED
department.
Self-assessment Evaluation/validation Levels Type of Comments
methods validation
Experienced Verbal Beginner Orientation
Need practice Demonstration/observation Intermediate Annual
Never done Practical exercise Expert Other
Not applicable (based Interactive class ________
on scope of practice)
_________________________________ _________________________________
Employee signature Observer signature
Source: Competency Management for the Emergency Department, HCPro, Inc., 2005