Procedural Competency Form



Procedural Competency Form

Endotracheal Intubation

Resident:_______________________________________ Date:__________________

Observing faculty:________________________________

Checklist of performance:

|Pre-procedure |Yes |No |N/A |

|Obtains informed consent when appropriate | | | |

|Evaluates airway for potential difficulty | | | |

|Pre-oxygenates patient | | | |

|Prepares and checks equipment | | | |

|Positions patient correctly | | | |

|Verbalizes back-up plan to supervising physician | | | |

|Procedure | | | |

|Observes universal precautions | | | |

|Orders appropriate medications | | | |

|Correct timing of medications delivered | | | |

|Utilizes cricoid pressure appropriately | | | |

|Maintains cervical stabilization (if applicable) | | | |

|Initiates intubation attempt at correct time | | | |

|Utilizes the laryngoscope appropriately | | | |

|Handles and passes ET tube appropriately | | | |

|Recognizes need to abort attempt and oxygenate | | | |

|Initiates back up plan appropriately if indicated | | | |

|Post-procedure | | | |

|Verifies tube position | | | |

|Secures tube | | | |

|Orders and reviews post intubation chest x-ray | | | |

|Orders appropriate ventilator settings | | | |

|Orders appropriate chemical sedation if indicated | | | |

Assessment (circle one): Unsatisfactory Satisfactory

Comments:

Faculty signature:______________________________________________________________

Resident signature:_____________________________________________________________

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