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Gastroenterology/Endoscopy Skills Checklist

My responses in this checklist represent a true reflection of my experience and comfort level. Please self-rate your comfort level in performing tasks in connection with the below checklist. Rate your level of comfort for each line item by following the below ranking system. Simply fill in the appropriate option immediately following the rating number.

* Typed Name (typing your name below serves as an electronic signature)

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Certifications: (Check all that apply)

BLS/BCLS/CPR
ACLS

Level of Comfort/Experience

N/A=Non-applicable
1=Inexperienced in this area
2=Limited comfort/experience in this area
3=Comfortable/experienced in this area
4=Very comfortable/highly experienced in this area

Procedures, Assist or Knowledge of	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Anoscopy	N/A	1	2	3	4
Bronchoscopy	N/A	1	2	3	4
Colonoscopy	N/A	1	2	3	4
EGD	N/A	1	2	3	4
ERCP	N/A	1	2	3	4
Flexible Sigmoidoscopy	N/A	1	2	3	4
IV Drip	N/A	1	2	3	4
Proper Assessment and Documentation of Conscious Sedation Record	N/A	1	2	3	4
Rigid Protoscopy	N/A	1	2	3	4
Sphincterotomy	N/A	1	2	3	4
Accessory Equipment	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Cytology Brushes	N/A	1	2	3	4
Decompression Tubes	N/A	1	2	3	4
Dilators : Balloon	N/A	1	2	3	4
Dilators : Maloney	N/A	1	2	3	4
Dilators : Savory	N/A	1	2	3	4
Forceps	N/A	1	2	3	4
Foreign Body Equipment	N/A	1	2	3	4
Polyp Snares	N/A	1	2	3	4
Valley Lab BX	N/A	1	2	3	4
Bleeder Cart Equipment	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Bicap Unit	N/A	1	2	3	4
Code Blue Lavage Kit	N/A	1	2	3	4
Endo Pump	N/A	1	2	3	4
Esophageal Banding	N/A	1	2	3	4
Gold Probe/Injector Needle	N/A	1	2	3	4
Scero Needles and Meds	N/A	1	2	3	4
Gastro-Intestinal Feeding Tubes	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Jejunal feeding tube	N/A	1	2	3	4
Naso-Enteric Tube	N/A	1	2	3	4
Peg Insertion Equipment	N/A	1	2	3	4
Replacement Gastrostomy Buttons	N/A	1	2	3	4
Replacement Gastrostomy Tubes	N/A	1	2	3	4
ERCP	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Equipment and Stock	N/A	1	2	3	4
Papillatomy	N/A	1	2	3	4
Som Procedure	N/A	1	2	3	4
Stent Placement	N/A	1	2	3	4
Specimen Collection	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Biopsies	N/A	1	2	3	4
Cytology	N/A	1	2	3	4
Immuno Suppressed Protocol	N/A	1	2	3	4
Manometry and Diagnostic Testing	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
24 Hour PH Ambulatory Study	N/A	1	2	3	4
Esophogeal Manometry	N/A	1	2	3	4
Liver BX	N/A	1	2	3	4
Paracentesis	N/A	1	2	3	4
Pediatric Procedures	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Pediatric Peg Cart	N/A	1	2	3	4
Proper EGD Scopes According to Age	N/A	1	2	3	4
Specific Equipment for Pediatric Scopes	N/A	1	2	3	4
Cleaning	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Proper Scope Cleaning	N/A	1	2	3	4
Proper Use of Scope Washers	N/A	1	2	3	4
Storing Scopes	N/A	1	2	3	4
Use of Leak Tester	N/A	1	2	3	4